Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices.

Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.

Barriers to screening for hepatitis B virus infection in Asian Americans.

BACKGROUND: Routine screening for hepatitis B virus (HBV) infection can identify individuals who need vaccination or treatment, as vaccination can prevent HBV infection. Although the overall prevalence of HBV infection in the United States is low (<1%), it is high (~10%) in Asian Americans. However, HBV screening rates in this population have been reported to be low. AIMS: This article systemically reviews the reported prevalence of HBV infection, the rate of HBV screening and access to HBV care, barriers for HBV screening and care, and a possible approach for improving HBV screening in Asian Americans. METHODS: Articles published from 1999 to 2011 on HBV screening and disparity in Asian Americans were identified by searching electronic databases (PubMed and Cochrane Library), and reviewed. RESULTS: Published studies, including a recent report from the Institute of Medicine of the National Academies, revealed HBV screening rates are low in Asian Americans. This review addresses the need for HBV screening in Asian Americans. Barriers to HBV screening are related to patients, providers, and/or the healthcare system. Screening programs that incorporate culturally sensitive interventions and include educational outreach, vaccination, and a link to healthcare services improve rates of HBV screening and vaccination in this at-risk community. CONCLUSIONS: A strategy that integrates efforts from the healthcare profession, federal agencies, and the community will be needed to improve HBV screening and access to HBV care for Asian Americans.

Persistence and adherence to nucleos(t)ide analogue treatment for chronic hepatitis B.

BACKGROUND & AIMS: Long-term treatment with nucleos(t)ide analogues (NUCs) is associated with increasing rates of antiviral drug resistance. Medication adherence is important in preventing drug resistance. This study aimed to determine, first, the persistence rates and the adherence rates to NUCs in patients with chronic hepatitis B (CHB), and second, the factors associated with adherence. METHODS: Pharmacy claims of three cohorts of patients with CHB who were receiving lamivudine, adefovir, or entecavir in January 2007, January 2008, and January 2009, and data of patients receiving tenofovir in January 2009, were analyzed. Persistence was defined as continuing acquisition of pharmacy claims during a 12-month period and adherence as the percent of days in which patients had medication during the period in which the medication was prescribed. RESULTS: A total of 11,100 patients were included, 4.7% were patients newly started on a NUC and 95.3% were existing patients already on a NUC at the start of each year. The mean ± SD persistence rate was 81 ± 3.8%, and was higher among existing patients than among new patients, 81.4% vs. 73.4% (p < 0.001). The mean ± SD adherence rate was 87.8 ± 19.1% and was higher among existing patients than among new patients, 88% vs. 84.6% (p = 0.001). Multivariate analysis showed that new patients (OR = 0.68, 95% CI 0.53-0.86), those receiving lamivudine (OR = 0.66, 95% CI 0.58-0.76), and young adult patients (OR=0.82, 95% CI 0.74-0.91) were less likely to have adherence rate > 90%. CONCLUSIONS: Persistence and adherence to NUCs were high among CHB patients. Counseling of young and/or new patients on medication adherence may decrease the rate of antiviral drug resistance.

Compact quadruple therapy with the lamivudine/zidovudine combination tablet plus abacavir and efavirenz, followed by the lamivudine/zidovudine/abacavir triple nucleoside tablet plus efavirenz in treatment-naïve HIV-infected adults.

PURPOSE: To assess efficacy, safety, and adherence with compact quadruple therapy comprising one lamivudine 150-mg/zidovudine 300-mg tablet (COM) twice daily + one abacavir (ABC) 300-mg tablet twice daily + three efavirenz (EFV) 200-mg capsules at bedtime for 24 weeks, followed by one lamivudine 150-mg/zidovudine 300-mg/ABC 300-mg triple nucleoside tablet (TZV) twice daily + three EFV 200-mg capsules at bedtime for 24 weeks. METHOD: A pilot 48-week, prospective, open-label trial in which 38 antiretroviral-naïve HIV-infected adults (baseline median HIV-1 RNA 5.1 log(10) copies/mL, CD4+ cell count 285/microL) received the above treatment and were monitored regularly with respect to plasma HIV-1 RNA levels, CD4+ cell counts, T-cell receptor excision circles (TRECs), adherence, and adverse events. RESULTS: At Week 48, intent-to-treat, switch-included analysis showed plasma HIV-1 RNA levels <400 copies/mL in 100% (29/29) of patients and <50 copies/mL in 93% (27/29); 59% of patients who achieved <50 copies/mL had <3 copies/mL (16/27). Similar virologic suppression was observed in patients with baseline HIV-1 RNA above or below 100000 copies/mL. HIV-1 RNA and CD4+ cell counts changed from baseline by a median of -3.4 log(10) copies/mL and +172 cells/microL, respectively. One virologic failure occurred at Week 16. Median TRECs/100000 peripheral blood lymphocytes increased 6-fold between baseline and Week 48. Median adherence rates were consistently 100% by self-report and 94% by pill count. Grade 2-4 treatment-related adverse events included dreams (16%), nausea (13%), decreased white cells (8%), dizziness (8%), sleep disorders (8%), and malaise and fatigue (8%). A suspected ABC hypersensitivity reaction occurred in 8% (3/38) of patients. CONCLUSION: COM/ABC/EFV or TZV/EFV produced potent, durable virologic suppression and immunologic benefits, was associated with high adherence rates, and was generally well tolerated.

The changing face of Canadian home parenteral therapy.

This article describes the Calgary Health Region Home Parenteral Therapy Program (HPTP), which has successfully shifted infusion therapies such as anti-infectives, analgesics, hydration, vasodilators, glucocorticoids, and iron-chelating agents from the hospital to patients' homes. Particular attention is given to the parenteral administration of anti-infectives, which currently accounts for more than 95% of program adult therapy days.

Outpatient parenteral antibiotic therapy: evolution of the Calgary adult home parenteral therapy program.

In the past 25 years, outpatient antibiotic therapy has been recognized as a cost-effective, safe and patient-accepted means of managing patients with chronic infections who require prolonged parenteral therapy but otherwise do not need admission to hospital. We describe the home parenteral therapy program in Calgary, which reflects the next generation of outpatient antibiotic therapy in Canada because of its unique inclusion of patients with acute infections. The Calgary home parenteral therapy program has evolved from a few, small, single-site programs to a multisite, region-wide program that each year treats thousands of patients who require long- and short-term parenteral therapy. With escalating health care budgets and increased demand on acute-care hospital beds, existing programs in other centres may benefit from the Calgary experience, and this home parenteral therapy model may serve as a template for developing new outpatient antibiotic therapy programs in other regions.

Prospective, intensive study of metabolic changes associated with 48 weeks of amprenavir-based antiretroviral therapy.

To determine whether a 48-week course of amprenavir-based antiretroviral therapy is associated with metabolic alterations, 14 clinically stable human immunodeficiency virus (HIV)-infected, protease inhibitor-naive adults initiated amprenavir-based triple therapy. Twelve subjects (86%) achieved HIV RNA levels of <400 copies/mL at week 24. Fasting glucose and insulin levels did not change. Insulin sensitivity did not decrease in the first 24 weeks, but a trend toward a decrease appeared at week 48. Six subjects experienced onset or worsening of glucose tolerance by week 24. Levels of fasting triglycerides and low-density lipoprotein, high-density lipoprotein, and total cholesterol increased. Bone mineral content, lean tissue, total fat, trunk fat, limb fat, and the ratio of trunk to limb fat increased at week 48. Amprenavir-based therapy was associated with increases in serum lipid levels but no short-term decrease in insulin sensitivity. A trend toward insulin resistance appeared late in the study following weight gain, particularly of trunk fat, but without loss of limb fat.