Appropriate enoxaparin dose for venous thromboembolism prophylaxis in patients with extreme obesity.

OBJECTIVE: To evaluate the appropriate dose of enoxaparin for venous thromboembolism (VTE) prophylaxis in patients with extreme obesity. METHODS: A literature search was performed using MEDLINE (1950-April 2013) to analyze all English-language articles that evaluated incidence of VTE and/or anti-Xa levels with enoxaparin for thromboprophylaxis in patients with extreme obesity. RESULTS: Eight studies were included in the analysis. Six of the studies were done in patients undergoing bariatric surgery. Mean body mass index ranged from 44.9 to 63.4 kg/m(2) within studies. Studies done with bariatric surgery patients utilized doses of enoxaparin that ranged from the standard dose of 30 mg subcutaneous (SQ) every 12 hours to 60 mg SQ every 12 hours. Other studies evaluated doses ranging from 40 mg SQ every 24 hours to 0.5 mg/kg/day. Only 3 studies evaluated the incidence of VTE as the primary endpoint; the other studies evaluated anti-Xa levels. The studies showed that appropriate anti-Xa levels were achieved more often with higher than standard doses of enoxaparin. One study showed that enoxaparin 40 mg SQ every 12 hours decreased the incidence of VTE in patients undergoing bariatric surgery compared to standard doses. Overall risk of bleeding was similar between study groups. CONCLUSIONS: Higher than standard doses of enoxaparin may be needed for patients with extreme obesity. Patients undergoing bariatric surgery may benefit from enoxaparin 40 mg SQ every 12 hours. Additional large randomized, controlled trials are needed to determine the efficacy and safety of higher than standard doses of enoxaparin for VTE prophylaxis in patients with extreme obesity.

Comparison of the efficacy and safety of two different insulin infusion protocols in the medical intensive care unit.

BACKGROUND: New guidelines recommend using less intensive glycemic goals in critically ill patients receiving insulin infusions. OBJECTIVE: To compare the efficacy and safety of a modified insulin infusion protocol (MIIP) with less stringent blood glucose (BG) goals to an intensive insulin infusion protocol (IIIP) in patients in a medical intensive care unit (MICU). METHODS: Retrospective review of patients receiving an insulin infusion for at least 24 hours. Patients treated for hyperglycemic emergencies were excluded. The primary endpoint of the study was mean area under the BG curve (BG-AUC) at 24 and 48 hours. Other endpoints included mean BG, hours until BG at goal, rate of BG above goal, frequency of BG measurements, and rate of hypoglycemia. RESULTS: BG-AUC at 24 hours was similar between the groups (MIIP = 5177.7 ± 1221.3 mg/dL x h vs IIIP = 4850.3 ± 1301.7 mg/dL x h; P = .20). The mean BG level at 24 hours was 225.1 ± 91.1 mg/dL in the MIIP group and 205.7 ± 89.7 mg/dL in the IIIP group (P = .06). In the MIIP group, 61.7% of the BG levels were above goal as compared to 87.5% in the IIIP group (P < .0001). Patients were able to achieve BG goals faster with the MIIP (12.58 ± 10.5 hours vs 29.37 ± 16.8 hours; P < .001). The rate of severe hypoglycemia was lower at 24 hours in the patients following the MIIP (0% vs 0.3%; P = .01). CONCLUSION: The study showed that by having less intensive glycemic goals, goal BG levels can achieved faster and the rate of severe hypoglycemia can decrease.

Evaluation of the Stroke-Specific Quality-of-Life (SSQOL) Scale in Mexico: A Preliminary Approach.

OBJECTIVES: The prevalence of stroke survivors with incomplete recovery in society has been estimated at 460/100,000 people, and one third of them require help in at least one daily activity. Two thirds of all deaths related to stroke in the world occur in low- and middle-income countries. The objective of the present work was to assess the reliability and validity of the previously translated Spanish Stroke-Specific Quality-of-Life (SSQOL) version 2.0 scales in Mexican stroke survivors. METHODS: An observational and cross-sectional pilot study was conducted. Thirty-one patients who suffered stroke up to 1 year prior to the present study were included. Patients were interviewed twice in a 7-day period; other indexes and scales were applied. The reliability was assessed by using Cronbach's alpha (internal consistency) and test-retest by using Spearman's rho scores; the acceptability was evaluated by the floor and ceiling effects. RESULTS: Ceiling and floor effects were observed for fewer than 20% of the patients. The overall internal consistency of the questionnaire was greater than 0.7 (Cronbach's α), with only two domains (family roles and personality) having lower internal consistency values. The results displayed high test-retest reliability: all domains had Spearman's rho scores of over 0.8. The questionnaire has adequate construct validity. CONCLUSIONS: Our preliminary results showed that the psychometric properties (acceptability and reliability) of the Spanish SSQOL questionnaire are good, encouraging, and comparable to those of other similar studies. This study is the first approach to validate the Spanish version of the SSQOL questionnaire in Mexican stroke survivors.

Daptomycin therapy for vancomycin-resistant enterococcal bacteremia: a retrospective case series of 30 patients.

STUDY OBJECTIVE: To determine clinical and microbiologic outcomes of daptomycin for the treatment of bacteremia caused by vancomycin-resistant enterococci (VRE). DESIGN: Retrospective medical record review. SETTING: Academic tertiary care hospital. PATIENTS: Thirty patients (median age 59 yrs, range 19-79 yrs, 50% male) who received daptomycin for the treatment of VRE bacteremia between January 2004 and July 2007. MEASUREMENTS AND MAIN RESULTS: Patients were included if they received daptomycin and had a blood culture positive for VRE at the time daptomycin was started. The primary end point was microbiologic cure, defined as negative blood cultures for VRE at the end of therapy. Secondary outcomes were clinical outcomes, adverse events, and occurrence of elevated creatine kinase levels. Clinical outcomes were judged as positive, negative, or indeterminate. The median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 17 (range 7-34), and 20 patients (67%) were in the intensive care unit. Patients received daptomycin for a median of 13 days (range 1-42 days), and the median dose administered was 6 mg/kg (range 3.7-8 mg/kg). Microbiologic cure was achieved in 24 patients (80%), and clinical success occurred in 17 patients (59% [one patient had an indeterminate clinical outcome and was excluded from this analysis]). All patients with a positive clinical outcome had microbiologic cure, six patients who died had microbiologic cure, and all patients with microbiologic failure died. On multivariable logistic regression, higher APACHE II score was associated with a lower chance of microbiologic success (adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.56-0.95). Lower APACHE II score (AOR 0.86, 95% CI 0.74-1.0) and daptomycin dose of 6 mg/kg or more (AOR 7.29, 95% CI 1.02-52.0) were associated with clinical success. Adverse drug events possibly attributable to daptomycin were uncommon. Three patients had fever possibly related to daptomycin, and two patients had mild elevations of creatine kinase level. CONCLUSION: Our experience suggests that daptomycin may be an acceptable option for VRE bacteremia; however, larger studies should be performed before this antimicrobial is routinely used for this indication.