Lorazepam versus chlordiazepoxide for the treatment of alcohol withdrawal syndrome and prevention of delirium tremens in general medicine ward patients.

Alcohol withdrawal syndrome (AWS) is a serious complication of abrupt alcohol cessation. Severe AWS can develop into delirium tremens (DT), which is potentially life-threatening. Lorazepam (LOR) and chlordiazepoxide (CDE) are mainstays of therapy for AWS. Current literature lacks studies comparing outcomes between the two drugs for patients who are not in a de-addiction ward specifically for withdrawal treatment. The primary objective of the study was to determine the incidence rate of DT between the groups. Of 2112 patients screened, 142 met inclusion criteria (LOR = 74, CDE = 68). Baseline characteristics were similar between groups. No significant difference in the primary outcome of DT development was observed (7% LOR, 9% CDE; p = 0.76). No significant differences in cumulative doses of scheduled LOR or CDE were observed (LOR 14.6 ± 8 mg, CDE 15.4 ± 12; p = 0.64). However, significant differences were found in the amount of "as needed" (PRN) LOR required for the two groups (LOR 3.2 ± 4 mg, CDE 6.6 ± 13 mg; p = 0.03) and the amount of scheduled plus PRN LOR required (LOR 17.7 ± 10 mg, CDE 21.9 ± 14 mg; p = 0.04). Doses are reported in LOR equivalents. There were no observed differences in duration of treatment (LOR 3.6 ± 1.3 days, CDE 3.9 ± 2.1 days; p = 0.3) or length of stay (LOR 5.28 ± 3.8 days, CDE 4.73 ± 4.2 days p = 0.4). No adverse events related to BZD were noted in either group. Hospital outcomes did not differ between the groups, but patients treated with CDE may require more adjuvant therapy to control symptoms of AWS. Both agents appear equally effective at preventing the development of DT in those patients admitted to general medicine wards.

ß-Blockade in Heart Failure With Reduced Ejection Fraction: Does Heart Rate Control Influence Readmissions?

BACKGROUND: Raised resting heart rate (HR), >70 beats per minute (bpm), has been shown to be a risk factor for adverse cardiovascular outcomes and hospital readmissions, specifically in patients with heart failure with reduced ejection fraction (HF rEF). Given their mortality benefit, ß-blockers are recommended in HF rEF, with a goal to titrate to a maximum tolerated dose rather than a specific HR target. OBJECTIVE: To determine the impact of optimal HR control achievement prior to hospital discharge on hospital readmissions in patients with HF rEF receiving ß-blockade. METHODS: A retrospective study of patients admitted to 5 adult hospitals within a large urban health-care system, between 2013 and 2015, was conducted. Patients were identified via International Classification of Diseases, Ninth Revision ( ICD-9) coding for acute on chronic HF rEF. RESULTS: Of the 225 patients included, 20% achieved optimal HR control (n = 46, HR <70 bpm; n = 179, HR ≥70 bpm) and only 15% received ß-blocker titration during hospital admission. Of note, 25% of patients receiving ≥50% target dose (n = 79) and 28% receiving 100% target dose (n = 39) achieved optimal HR control. At 30 days, patients with an HR <70 bpm versus HR ≥70 bpm exhibited similar readmission rates (9% vs 11%, respectively; P > .99) and ED visits (11% vs 8%, respectively; P = .57). CONCLUSIONS: Readmission rates were similar among patients with HF rEF despite the majority failing to achieve optimal HR control from ß-blockade. However, ß-blocker dosing remains suboptimal relative to guideline-recommended target doses. Opportunities exist for inpatient clinicians to optimize ß-blockade in an attempt to achieve HR control.

Underutilization of Aldosterone Antagonists in Heart Failure.

Background: Treatment with an aldosterone antagonist (AA) has been shown in multiple trials to reduce heart failure (HF)-related morbidity, mortality, and hospital readmission. American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) treatment guidelines recommend the use of an AA in all HF patients with an ejection fraction ≤35% and no known contraindication. Several studies have documented underuse of AA. Objectives: To determine the proportion of patients who received AA therapy consistent with the ACCF/AHA guidelines. Secondary objectives included determining the proportion of patients who received an AA inconsistent with guidelines and 30- and 90-day readmission rates. Methods: A retrospective chart review was conducted of patients admitted to an inner city academic medical center with a diagnosis of HF between August 16, 2011, and June 5, 2013. Results: A total of 346 HF admissions (87.6% African American) were evaluated. Use of an AA at discharge was consistent with guidelines in 31% of patients. A total of 121 patients (35%) were discharged on an AA. Among the remaining 225 patients who were not discharged on an AA, 170 (75.6%) had no contraindication to therapy. Sixty-one patients were readmitted within 30 days, and a total of 108 patients were readmitted within 90 days. There were no significant differences in readmission rates between patients who were discharged on AA therapy and those who were not. Conclusion: AAs are still underutilized in the treatment of HF.

New Treatment Option for Chronic Obstructive Pulmonary Disease: Two Long-Acting Bronchodilators in a Single Metered-Dose Inhaler.

Combination long-acting inhaled bronchodilators are central to the management of patients with moderate to very severe chronic obstructive pulmonary disease. Glycopyrrolate is a long-acting muscarinic antagonist (LAMA), and formoterol fumarate is a long-acting beta2 agonist (LABA). In randomized controlled trials, this LAMA/LABA combination in a metered-dose inhaler was shown to be effective in improving pulmonary function and quality of life. Clinicians now have the availability of 3 delivery systems for LAMA/LABA therapy, including metered-dose inhaler, dry-powder inhaler, and Soft Mist inhaler. On the basis of numerous patient factors, such as cognitive ability, manual strength/dexterity, and peak inspiratory flow, clinicians may select the most appropriate inhalation device. For each inhalation device, persistent patient education is absolutely essential, including observation of patient use. International evidence-based guidelines stress the critical importance of ensuring correct use of inhalation devices.

Teaching-Learning Experience Regarding Skill in Using Inhalers: Medical Students Teaching Nursing Students.

BACKGROUND: Teaching-learning experience involving more than one health care discipline is a topic of great interest in the health sciences. Few such experiences are known in which medical students taught nursing students a clinical skill. METHOD: The authors evaluated the effect of fourth-year medical students teaching the correct use of a metered-dose inhaler (MDI) to bachelor of science nursing (BSN) students. An fourth-year medical student investigator taught BSN students the correct use of an MDI in individual, private educational sessions, approximately 10 minutes in length, in a large health sciences center. BSN students were scored in use of MDI preeducation and posteducation. Instruction included both discussion and demonstration by the M4S. RESULTS: Among 20 BSN students, posteducation scores were markedly improved for total steps (p < .0001), and six of nine individual steps for MDI use. CONCLUSION: Brief teaching-learning sessions are effective in teaching nursing students the correct use of MDI. [J Nurs Educ. 2017;56(2):120-122.].

Asthma associated with the use of cocaine, heroin, and marijuana: A review of the evidence.

OBJECTIVE: A review of the evidence was conducted regarding asthma associated with the use of cocaine, heroin, and marijuana. DATA SOURCES: A search of the English literature was performed via PubMed/Medline and EMBASE using the search terms asthma AND cocaine, heroin, and marijuana. When pertinent articles were found, salient references in those articles were assessed. STUDY SELECTION: Due to the relatively small number of studies, we included all studies and cases. RESULTS: For several decades, case reports, retrospective studies, and laboratory investigations have demonstrated that inhalation of cocaine or heroin is associated with increased asthma symptoms and reduced pulmonary function. Smoking crack cocaine, nasal insufflation of cocaine or heroin, and smoking heroin increases the risk of emergency department visits and hospitalizations for asthma. Although frequent smoking of marijuana may cause symptoms of cough, sputum production, and wheezing in the general population, more studies are needed specifically in patients with asthma. Smoking marijuana with concomitant tobacco use is common and further worsens the respiratory symptoms. CONCLUSIONS: Use of cocaine and heroin in patients with asthma should be avoided. Pending further studies, it would be prudent for patients with asthma to avoid smoking marijuana. Clinicians need to be vigilant regarding use of these drugs in their patients with hyperreactive airway disease.

Asthma as a Comorbidity in Hospitalized Patients: A Potential Missed Opportunity to Intervene.

Asthma is a frequent comorbidity in hospitalized children and adults. Patients with a history of asthma may have no breathing complaints or abnormal chest exam findings to trigger care for this comorbidity during hospitalization. Consequently, this may lead to a potential missed opportunity to discuss asthma as a comorbidity and ongoing issue to ensure its optimal management at home. Our goal is to raise awareness that such patient encounters may represent opportunities for health care professionals to optimize asthma management. Despite focusing on the present illness and limited time availability, asthma care may be improved in a time-efficient manner in these patients.

Effect of diseases on response to vitamin K antagonists.

INTRODUCTION: The purpose of this review article is to summarize the literature on diseases that are documented to have an effect on response to warfarin and other VKAs. METHODS: We searched the English literature from 1946 to September 2015 via PubMed, EMBASE, and Scopus for the effect of diseases on response vitamin K antagonists including warfarin, acenocoumarol, phenprocoumon, and fluindione. DISCUSSION: Among many factors modifying response to VKAs, several disease states are clinically relevant. Liver disease, hyperthyroidism, and CKD are well documented to increase response to VKAs. Decompensated heart failure, fever, and diarrhea may also elevate response to VKAs, but more study is needed. Hypothyroidism is associated with decreased effect of VKAs, and obese patients will likely require higher initial doses of VKAs. CONCLUSION: In order to minimize risks with VKAs while ensuring efficacy, clinicians must be aware of the effect of disease states when prescribing these oral anticoagulants.

Effect of Body Weight on Dose of Vitamin K Antagonists.

OBJECTIVES: Numerous factors are well documented to affect the response to vitamin K antagonists (VKA), including dietary vitamin K, other drugs, age, pharmacogenetics, and disease states. Body weight is perhaps not as well known as a variable affecting VKA dose. Our aim was to review the literature regarding body weight and VKA dose requirements. METHODS: We reviewed the English-language literature via PubMed and Scopus using the search terms VKA, warfarin, acenocoumarol, phenprocoumon, fluindione, AND body weight. RESULTS: Among 32 studies conducted since the widespread use of the international normalized ratio, 29 found a correlation with body weight or body surface area and VKA dose requirement. Warfarin was evaluated in 27 studies and acenocoumarol, phenprocoumon, or fluindione were assessed in 5 investigations. CONCLUSIONS: Because of varying study methodologies, further study is warranted. Based on current evidence, clinicians should include body weight, along with other established variables when dosing VKA. Most important, obese and morbidly obese patients may require a 30% to 50% increase with the initial dosing of VKA.

Inhaler Use in Hospitalized Patients with Chronic Obstructive Pulmonary Disease or Asthma: Assessment of Wasted Doses.

BACKGROUND: Hospitalized patients with chronic obstructive pulmonary disease (COPD) or asthma routinely have inhaled medications ordered for acute and maintenance therapy. Treatment may be administered via metered-dose inhaler (MDI) or dry-powder inhaler (DPI). These products must be appropriately labeled to be released home with the patient or discarded before discharge. OBJECTIVE: To assess the amount and estimated cost of wasted doses of medications via MDI or DPI for hospitalized patients with COPD/asthma. METHODS: A retrospective study was conducted at a university-affiliated hospital. Patients admitted between January 2011 and June 2012 with a primary diagnosis of COPD or COPD with asthma and who were ≥40 years of age were included. Information collected included use of albuterol, ipratropium, inhaled corticosteroids, long-acting beta agonist, or tiotropium and whether treatments were given by nebulizer, MDI, MDI plus valved holding chamber (VHC), or DPI. The number of doses dispensed, as well as doses not used, via MDI, MDI + VHC, or DPI were collected from electronic medical records. Costs associated with wasted medications were evaluated. RESULTS: Of 555 patient admissions screened, 478 (mean age, 66 years; 58% women; 74% African American) met study criteria. Of the total MDI or DPI doses dispensed, 87% were wasted, and associated hospital cost was approximately $86,973. CONCLUSIONS: Substantial waste of inhaled medications was found in our study. Practical strategies are needed to reduce wasted inhalers. Further assessment of this problem is needed in other US hospitals.

Evaluation of the treatment of methicillin-resistant Staphylococcus aureus bacteremia.

BACKGROUND: Bloodstream infections are a leading cause of death in the United States. Methicillin-resistant Staphylococcus aureus (MRSA) encompasses >50% of all S aureus strains in infected hospitalized patients and increases mortality, length of stay and healthcare costs. The objective of this study was to evaluate the treatment of MRSA bacteremia with daptomycin, linezolid and vancomycin. METHODS: Patients with MRSA bacteremia between June 2008 and November 2010 were reviewed retrospectively. A microbiology laboratory report identified patients with ≥ 1 positive MRSA blood culture. Patients ≥ 18 years receiving daptomycin, linezolid or vancomycin for ≥ 7 consecutive days were included. Polymicrobial blood cultures and patients treated concomitantly with >1 anti-MRSA agent were excluded. RESULTS: Of 122 patients included, 53 received daptomycin, 15 received linezolid and 54 received vancomycin. Clinical and microbiologic cure rates were similar between daptomycin, linezolid and vancomycin (58.5% versus 60% versus 61.1%; 93.6% versus 100% versus 90%, respectively). Thirteen patients (daptomycin 4/24 versus linezolid 1/9 versus vancomycin 8/49, P = 0.5960) had recurrence while 12 patients had re-infection (daptomycin 5/42 versus linezolid 0/9 versus vancomycin 7/49, P = 0.4755). Treatment failure occurred in 11 patients treated with daptomycin, 4 with linezolid and 9 with vancomycin (P = 0.662). Compared with daptomycin and vancomycin, linezolid-treated patients had higher mortality (P = 0.0186). CONCLUSIONS: No difference in clinical or microbiologic cure rates was observed between groups. Daptomycin and vancomycin appear equally efficacious for MRSA bacteremia, whereas linezolid therapy was associated with higher mortality.

Fever as a risk factor for increased response to vitamin K antagonists: a review of the evidence and potential mechanisms.

Numerous factors affect the response to vitamin K antagonists (VKA) including age, dietary vitamin K, other drugs, pharmacogenetics, and disease states. In antithrombotic guidelines, fever is mentioned as a factor that may increase response to VKA. The purpose of this article is to review the available evidence regarding the effect of fever on response to VKA, and to discuss possible mechanisms of this effect. We performed a search of the English literature from 1943 to June 2014, using the key words fever AND warfarin, acenocoumarol, phenprocoumon, coumarin anticoagulants and VKA; fever AND vitamin K dependent clotting factors II, VII, IX, and X. One animal investigation and 6 studies in humans suggest fever increases response to VKA, but one study did not find a significant effect. The magnitude of this effect is variable. Possible mechanisms for the increased effect of VKA associated with fever are increased catabolism of vitamin K dependent clotting factors, decreased vitamin K intake, and inhibition of VKA metabolism. More rigorous studies are needed to confirm that fever increases response to warfarin and other VKA.

Graves' disease and treatment effects on warfarin anticoagulation.

Background. Hyperthyroidism causes an increased hypoprothrombinemic response to warfarin anticoagulation. Previous studies have demonstrated that patients with hyperthyroidism require lower dosages of warfarin to achieve a therapeutic effect. As hyperthyroidism is treated and euthyroidism is approached, patients may require increasing warfarin dosages to maintain appropriate anticoagulation. We describe a patient's varying response to warfarin during treatment of Graves' disease. Case Presentation. A 48-year-old African American female presented to the emergency room with tachycardia, new onset bilateral lower extremity edema, gradual weight loss, palpable goiter, and generalized sweating over the prior 4 months. She was admitted with Graves' disease and new onset atrial fibrillation. Primary stroke prophylaxis was started using warfarin; the patient developed a markedly supratherapeutic INR likely due to hyperthyroidism. After starting methimazole, her free thyroxine approached euthyroid levels and the INR became subtherapeutic. She remained subtherapeutic over several months despite steadily increasing dosages of warfarin. Immediately following thyroid radioablation and discontinuation of methimazole, the patient's warfarin dose and INR stabilized. Conclusion. Clinicians should expect an increased response to warfarin in patients with hyperthyroidism and close monitoring of the INR is imperative to prevent adverse effects. As patients approach euthyroidism, insufficient anticoagulation is likely without vigilant follow-up, INR monitoring, and increasing warfarin dosages.

Nitrofurantoin-induced hepatotoxicity: a rare yet serious complication.

Nitrofurantoin is a commonly prescribed antibiotic for the treatment of recurrent uncomplicated urinary tract infections. Its importance has been emphasized by the current international clinical practice guidelines for the management of uncomplicated cystitis. Since its introduction into clinical practice, nitrofurantoin has been associated with various adverse effects, including hepatotoxicity. We searched the English-language literature using PubMed and SCOPUS for the period 1961 through the end of February 2013. Key search terms included "nitrofurantoin AND hepatotoxicity" as well as "nitrofurantoin AND hepatitis." When studies or case reports were found, we assessed articles cited in those publications. A broad spectrum of liver toxicity associated with nitrofurantoin use has been reported, ranging from acute hepatitis, granulomatous reaction, cholestasis, or autoimmune-mediated hepatitis to chronic active hepatitis that could lead to cirrhosis or death. The mechanism of hepatotoxicity is poorly understood, but it is believed to be the result of an immunologic process or a direct cytotoxic reaction. It has been postulated that prolonged exposure to nitrofurantoin, female sex, advanced age, and reduced renal function increase the risk of developing hepatotoxicity. For the management of severe cases, corticosteroids have been used along with nitrofurantoin discontinuation. Because of mixed results, the utility of corticosteroids has not been proven and should be used judiciously. Given the severity and seriousness of the adverse effect of hepatotoxicity, clinicians should weigh the risks and benefits of nitrofurantoin before initiating therapy, especially in long-term prophylaxis in high-risk patients. Clinicians also should be well versed in recognizing and managing liver injury associated with nitrofurantoin.