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BACKGROUND: Aldosterone antagonists (AA) have historically been underutilized despite evidence that they reduce morbidity, mortality, and readmission rates to the hospital when used appropriately. OBJECTIVE: We sought to determine if AAs were being prescribed in accordance with the 2013 ACCF/AHA guidelines and if there was any benefit surrounding 30-day readmissions or 30-day mortality for patients taking AAs with heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF). METHODS: We performed a retrospective chart review of adult patients who were discharged between October 1, 2015 and February 1, 2016 with any ICD-10 code for heart failure to assess compliance with guideline directed medical therapy. At baseline, patients were stratified by HFpEF and HFrEF. Patients were excluded if they died during the admission, discharged with hospice care, received a heart transplant or ventricular assist device, if they were miscoded or left against medical advice. Descriptive statistics, and Chi Square were used to evaluate the data. RESULTS: We reviewed 601 patient charts for eligibility in our study, and determined 438 met the criteria for inclusion. Ninety-seven patients (22%) received an AA. Within the HFrEF group, only 37% of patients who were eligible per 2013 ACCF/AHA guidelines, received an AA at time of discharge. Fourteen percent of HFpEF patients were discharged on an AA. We found a trend towards decreased rates of our 30-day outcomes in patients who took AAs in both the HFpEF and HFrEF groups. CONCLUSIONS: AAs were underutilized during the timeframe we evaluated, despite the evidence for their use.
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Background: Aldosterone antagonists (AA) have historically been underutilized despite evidence that they reduce morbidity, mortality, and readmission rates to the hospital when used appropriately. Objective: We sought to determine if AAs were being prescribed in accordance with the 2013 ACCF/AHA guidelines and if there was any benefit surrounding 30-day readmissions or 30-day mortality for patients taking AAs with heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF). Methods: We performed a retrospective chart review of adult patients who were discharged between October 1, 2015 and February 1, 2016 with any ICD-10 code for heart failure to assess compliance with guideline directed medical therapy. At baseline, patients were stratified by HFpEF and HFrEF. Patients were excluded if they died during the admission, discharged with hospice care, received a heart transplant or ventricular assist device, if they were miscoded or left against medical advice. Descriptive statistics, and Chi Square were used to evaluate the data. Results: We reviewed 601 patient charts for eligibility in our study, and determined 438 met the criteria for inclusion. Ninety-seven patients (22%) received an AA. Within the HFrEF group, only 37% of patients who were eligible per 2013 ACCF/AHA guidelines, received an AA at time of discharge. Fourteen percent of HFpEF patients were discharged on an AA. We found a trend towards decreased rates of our 30-day outcomes in patients who took AAs in both the HFpEF and HFrEF groups. Conclusions: AAs were underutilized during the timeframe we evaluated, despite the evidence for their use
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Humanos , Masculino , Femenino , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Volumen Sistólico/efectos de los fármacos , Estudios Retrospectivos , Resultado del Tratamiento , Pautas de la Práctica en Medicina/estadística & datos numéricos , Prescripciones de Medicamentos/estadística & datos numéricosRESUMEN
Heart failure is one of the leading causes of hospitalizations in the United States, with >1 million admissions yearly and a 25% risk of readmissions within 1 month. In order to assist clinicians, we provide an update of the heart failure bibliography that was published in Pharmacotherapy in 2008, which followed the original bibliography published in 2004. A significant number of clinical trials and observational studies have been conducted since the early 1980s to guide management of heart failure patients. Major advances have occurred in the past 10 years, and our understanding of the diagnosis, prevention, and management of heart failure has evolved substantially during this time period. Specific areas of this review include heart failure risk factors, management of comorbid conditions, acute heart failure management, chronic heart failure management, advanced heart failure, device therapy, lifestyle modification, and medication and therapy management, including medication adherence. Key consensus guidelines and statements are also included. This bibliography of key heart failure papers aims to provide clinicians and their trainees with a valuable clinical reference resource and teaching tool that may be used to optimize the care of patients with heart failure.
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Insuficiencia Cardíaca/terapia , Hospitalización/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Enfermedad Aguda , Enfermedad Crónica , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Humanos , Estilo de Vida , Cumplimiento de la Medicación , Factores de Riesgo , Estados UnidosRESUMEN
PURPOSE: The use of a standardized knowledge test to assess postgraduate year 1 (PGY1) pharmacy residency training was evaluated. METHODS: This was a retrospective review of a prospectively administered exam. A bank of questions was developed by preceptors from each of the core rotation disciplines: general medicine (including ambulatory care and oncology), pediatrics, critical care (including transplantation), drug information, operations, practice management, and psychiatry. Board-certified pharmacy specialists at our institution were asked to submit 5-10 questions with answers that would likely be encountered by residents during rotation in their specific specialty area. The exam was administered at the beginning and the end of the resident's PGY1 year. RESULTS: A total of 49 PGY1 residents completed the examination during the first and last months of their residency training. Residents' overall scores improved 5-10% annually from baseline to completion of their residency. The mean overall exam score significantly improved from baseline after completion of a PGY1 residency at our institution for all four class years. All four residency classes demonstrated an increase from baseline scores in most core disciplines with the exception of practice management, which decreased every year of the examination. CONCLUSION: Scores on a standardized exam developed to assess the baseline knowledge of incoming PGY1 residents and the effect of one year of residency training improved in the majority of practice areas at the end of the year compared to scores at the beginning of the year.
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Competencia Clínica/normas , Evaluación Educacional/normas , Residencias en Farmacia/normas , Evaluación Educacional/métodos , Femenino , Humanos , Masculino , Residencias en Farmacia/métodos , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
A Postgraduate Year One (PGY1) resident's concerns, limitations, and strengths may be self-identified early in the residency year but are reliant on self-awareness and insight. Program directors commonly find difficulty in identifying a resident's specific knowledge deficits at the beginning of the program. A standardized resident examination can identify limitations early in training and these results can be incorporated into a tailored resident development plan. A total of sixty-two PGY1 residents completed the examination pre- and post-training over a five-year timespan. Scores increased in most core disciplines in each of the five years, indicating an overall improvement in resident knowledge throughout their PGY1 year. The approach of utilizing the scores for the resident's individualized plan allows for customization to ensure that the resident addresses knowledge gaps where necessary.
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PURPOSE: With the previous norepinephrine shortage, alternative agents were required to treat patients with septic shock. This retrospective study evaluated whether the shortage of norepinephrine had an adverse effect on patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock. METHODS: This was a retrospective chart review, which compared patients who received norepinephrine versus those who did not. Eligible patients were those ≥ 18 years old who were admitted to an intensive care unit with a diagnosis of sepsis and were initiated on a vasopressor to maintain hemodynamic stability. The specific primary endpoint was whether using norepinephrine versus other vasopressors had an effect on ICU length of stay. Secondary outcomes included mortality, blood pressure, mean arterial pressure, development of renal insufficiency, and vasopressor requirements. RESULTS: There were 288 patients screened and 214 patients who met the inclusion criteria (norepinephrine group=106 and nonnorepinephrine group=108). After accounting for potential differences in disease severity (APACHE II score), age, weight and gender, there was no difference in ICU length of stay (p=0.4); however, the odds of survival were 5.9 (95% CI: 3.1 to 11.1) times higher for those in the non-norepinephrine group (p<0.0001). CONCLUSION: Based on this retrospective analysis, patients that did not receive norepinephrine had a similar ICU LOS but had a higher rate of survival. The norepinephrine shortage did not have an adverse effect on patient outcomes.
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OBJECTIVE: To review the pharmacology, efficacy, and safety of vorapaxar, a protease activator receptor-1 (PAR-1) antagonist, in the management of atherosclerotic diseases. DATA SOURCES: Peer-reviewed clinical trials and review articles were identified from MEDLINE and Current Content database (both 1966 to December 31, 2014) using the search terms vorapaxar and protease activator receptor antagonist. STUDY SELECTION AND DATA EXTRACTION: A total of 30 clinical studies were identified (16 clinical trials, including subanalyses, 14 related to pharmacology, pharmacokinetics, and pharmacodynamics and drug interactions). DATA SYNTHESIS: Two phase III clinical trials with vorapaxar have been published. In patients with non-ST segment elevation myocardial infarction (MI), vorapaxar failed to significantly reduce the primary efficacy end point (composite of cardiovascular death, MI, stroke, recurrent ischemia with hospitalization, and urgent coronary revascularization). Conversely, in a study of secondary prevention for patients with cardiovascular disease, the composite end point of cardiovascular death, MI, or stroke was significantly reduced. In both trials, the safety end points of major/minor bleeding were increased compared with placebo. In the secondary prevention trial, an increased incidence of intracranial hemorrhage led to the exclusion of patients with a prior history of stroke. CONCLUSION: Vorapaxar is approved for use with aspirin and/or clopidogrel in the secondary prevention of cardiovascular events in stable patients with peripheral arterial disease or a history of MI. However, the addition of vorapaxar to other antiplatelets can significantly increase the risk of bleeding. It is, therefore, essential to balance the need for further reduction of risk of thrombotic event with patient's individual bleeding risk.
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Aterosclerosis/tratamiento farmacológico , Enfermedades Cardiovasculares/prevención & control , Lactonas/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Piridinas/uso terapéutico , Receptor PAR-1/antagonistas & inhibidores , Ensayos Clínicos Fase III como Asunto , Hemorragia/inducido químicamente , Humanos , Lactonas/efectos adversos , Infarto del Miocardio/prevención & control , Enfermedad Arterial Periférica/tratamiento farmacológico , Piridinas/efectos adversos , Riesgo , Prevención Secundaria , Accidente Cerebrovascular/prevención & control , Resultado del TratamientoRESUMEN
Background: Anticoagulation is standard practice for the prevention and treatment of thromboembolic events. Two of the newer agents, rivaroxaban (Xarelto) and dabigatran (Pradaxa) are being utilized frequently in the inpatient and outpatient settings. Prescribers may not appreciate the need for dose reduction in the setting of renal insufficiency. Objective: The objective of this study was to evaluate whether rivaroxaban and dabigatran were dosed according to recommendations in the package insert for patients with renal insufficiency. Methods: Eligible patients were those >18 years of age who received rivaroxaban or dabigatran as an inpatient or had a prescription filled from the outpatient pharmacy. The use of the Cockcroft-Gault equation was utilized to calculate creatinine clearance to evaluate whether patients had appropriate manufacturer recommended dose reductions based on their renal function. Results: There were very few patients (8 of 355, or 2.3%) who should have received a reduced dose when creatinine clearance was calculated utilizing actual body weight. In those patients with renal insufficiency, 3 of 6 (50.0%) patients receiving rivaroxaban and 1 of 2 (50%) patients receiving dabigatran were appropriately dosed. When ideal body weight was substituted for creatinine clearance calculation, there were 15 patients receiving rivaroxaban and 10 patients receiving dabigatran who fell below the creatinine clearance threshold for dose reduction. Conclusions: Based on this evaluation, very few patients required a dose reduction due to renal insufficiency. It is important for clinicians to always monitor renal function when utilizing these medications to optimize the benefits of the new oral anticoagulants while limiting potential deleterious effects. Furthermore, it is necessary to ensure that actual body weight is being utilized for creatinine clearance calculations with the new oral anticoagulants and not to base dosing on estimated glomerular filtration rate or other calculated creatinine clearance as this could lead to inappropriate dose reductions.
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OBJECTIVE: To review the literature surrounding the incidence, significance, and management of cardiovascular (CV) drug shortages. DATA SOURCES: A literature search was conducted using all available indexing databases from January 1996 to August 2013, coupled with assessments of the ASHP (American Society of Health System Pharmacists) and Food and Drug Administration Web sites designated to drug shortages. Data were also gathered through a review of listservs discussing this topic. DATA SYNTHESIS: CV drug shortages are among the top 5 national drug class shortages that are posing a threat to patient care and public health. When a drug shortage occurs, it requires modifications to prescribing and the method medications are processed by the pharmacy. These necessary yet cumbersome changes can potentially result in less-than-desirable prescribing options and increases in personnel time because of administrative and dispensing obstacles. Any one of these has the potential to increase costs and/or lead to worse outcomes. Several factors have been shown to contribute to these shortages, including manufacturing delays, increased demand, medication discontinuations, and lack of raw materials. In this article, we review 13 of the critical CV drug shortages, describe their role in therapy, discuss the reasons for the shortage, define their impact on patient care, and recommend alternative therapies. CONCLUSIONS: CV drug shortages are common and can potentially lead to deleterious patient outcomes. Institutions should develop plans for early identification, management, and resolution to minimize the clinical sequelae associated with drug shortages.
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BACKGROUND: The potency of intravenous bumetanide to furosemide using a ratio of 1:40 has been suggested; however, there are little data supporting this ratio. Recent drug shortages required the use of bumetanide in a large patient population, enabling further characterization of the efficacy of IV bumetanide. OBJECTIVE: The primary objective of this study was to estimate a dose-response effect of IV bumetanide on urine output (UOP) in all patients that received 48 hours of therapy as well as in a subgroup of patients with heart failure (HF). This subgroup was used to compare the potency of bumetanide with furosemide. A secondary safety objective described electrolyte replacement required during therapy. METHODS: This was a single-center retrospective study examining the dose-response effect of IV bumetanide in patients receiving at least 48 hours of intermittent (iIV) or continuous (cIV) dosing, measured by UOP per mg of drug received (mL/mg). The potency of IV bumetanide was compared with furosemide in a subset of patients with HF using pre-existing data. The safety of IV bumetanide was analyzed by quantifying electrolyte replacement received during the study period. RESULTS: The primary outcome was higher in the iIV group (n=93) at 1273 ± 844 mL/mg compared with the cIV group (n=16) at 749 ± 370 mL/mg (P=0.002). Among patients with HF who received furosemide (iIV n=30, cIV n=26) or bumetanide (iIV n=30, cIV n=3), a potency ratio of 41:1 was found for the iIV group and 34:1 for all patients with HF. There was no significant difference in electrolyte replacement between groups. CONCLUSIONS: A greater response was seen with intermittent bumetanide compared with continuous infusion bumetanide. This study supports the 40:1 dose equivalence ratio (furosemide:bumetanide) in patients with HF receiving at least 48 hours of intravenous intermittent bumetanide.
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OBJECTIVE: To assess the evolution and effectiveness of the Academician Preparation Program to provide knowledge and skills in teaching and evaluating to pharmacy residents, as well as generate interest in academic careers. DESIGN: Participants attended seminars and participated in additional teaching, precepting, facilitating, and evaluating activities. Residents maintained a teaching portfolio and met with a faculty mentor quarterly to review their progress toward completion of the requirements for the Academician Preparation Program certificate. ASSESSMENT: Since the program was first offered in 2005, it has expanded to 7 sites throughout the state. As of June 2012, 155 residents had completed the program and 20 (13%) had accepted full-time academic positions. Many others were serving as adjunct faculty members or preceptors. The majority of those enrolled in pharmacy residencies completed the program. CONCLUSION: An optional, organized academic preparation program was of interest to residents, fostered academic careers, and helped meet residency accreditation guidelines.
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Selección de Profesión , Educación de Postgrado en Farmacia/métodos , Docentes , Internado no Médico , Facultades de Farmacia , Curriculum , Retroalimentación , Humanos , Preceptoría , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Enseñanza/métodos , Factores de TiempoRESUMEN
Background: The potency of intravenous bumetanide to furosemide using a ratio of 1:40 has been suggested; however, there are little data supporting this ratio. Recent drug shortages required the use of bumetanide in a large patient population, enabling further characterization of the efficacy of IV bumetanide. Objective: The primary objective of this study was to estimate a dose-response effect of IV bumetanide on urine output (UOP) in all patients that received 48 hours of therapy as well as in a subgroup of patients with heart failure (HF). This subgroup was used to compare the potency of bumetanide with furosemide. A secondary safety objective described electrolyte replacement required during therapy. Methods: This was a single-center retrospective study examining the dose-response effect of IV bumetanide in patients receiving at least 48 hours of intermittent (iIV) or continuous (cIV) dosing, measured by UOP per mg of drug received (mL/mg). The potency of IV bumetanide was compared with furosemide in a subset of patients with HF using pre-existing data. The safety of IV bumetanide was analyzed by quantifying electrolyte replacement received during the study period. Results: The primary outcome was higher in the iIV group (n=93) at 1273 ± 844 mL/mg compared with the cIV group (n=16) at 749 ± 370 mL/mg (P=0.002). Among patients with HF who received furosemide (iIV n=30, cIV n=26) or bumetanide (iIV n=30, cIV n=3), a potency ratio of 41:1 was found for the iIV group and 34:1 for all patients with HF. There was no significant difference in electrolyte replacement between groups. Conclusion: A greater response was seen with intermittent bumetanide compared with continuous infusion bumetanide. This study supports the 40:1 dose equivalence ratio (furosemide:bumetanide) in patients with HF receiving at least 48 hours of intravenous intermittent bumetanide (AU)
Antecedentes: Se ha sugerido que existe un ratio de potencia de la bumetanida con la furosemida de 1:40; sin embargo, hay pocos estudios que soporten este ratio. Recientes desabastecimientos requirieron el uso de bumetanida en una población grande de pacientes, lo que permitió una caracterización extensiva de la eficacia de la bumetanida IV. Objetivo: El objetivo primario de este estudio fue estimar la respuesta dosis-efecto de la bumetanida IV en la diuresis en todos los pacientes que recibieron 48 horas de tratamiento, así como en el subgrupo de pacientes con fallo cardiaco. Este subgrupo fue utilizado para comparar la potencia de la bumetanida con la furosemida. Un objetivo secundario de seguridad describió el reemplazo de electrolitos necesario durante el tratamiento. Métodos: Este fue un estudio unicéntrico retrospectivo que examinó el la respuesta dosefecto de la bumetanida IV en pacientes que la recibieron al menos 48 horas intermitentemente (iIV) o continua (cIV), medida por la diuresis por mg de medicamento recibido (mL/mg). La potencia de la bumetanida IV se comparó en la furosemida en un subgrupo de pacientes con fallo cardiaco utilizando datos pre-existentes. La seguridad de la bumetanida IV se analizó cuantificando el reemplazo electrolítico recibido durante el periodo de estudio. Resultados: El resultado primario fue mayor en el grupo iIV (n=93) con 1273 (SD=844) mL/mg, que en el grupo cIV (n=16) con 749 (SD=370) mL/mg (p=0,002). Entre los pacientes con fallo cardiaco que recibieron furosemida (iIV n=30, cIV n=26) o bumetanida (iIV n=30, cIV n=3) se encontró un ratio de potencia de 41:1 para el grupo iIV y de 34:1 para todos los pacientes con fallo cardiaco. No hubo diferencia significativa en el reemplazo electrolítico entre ambos grupos. Conclusión: Se encontró una respuesta mayor con la bumetanida intermitente que con la bumetanida en perfusión continua. Este estudio apoya el ratio de dosis equivalente de 40:1 (furosemida:bumetanida) en pacientes con fallo cardiaco que reciben al menos 48 horas de bumetanida intravenosa intermitente (AU)
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Humanos , Masculino , Femenino , Inyecciones Intravenosas/organización & administración , Furosemida/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/prevención & control , Equivalencia Terapéutica , Inyecciones Intravenosas/instrumentación , Inyecciones Intravenosas/métodos , Estudios Retrospectivos , Furosemida/metabolismo , Furosemida/farmacocinéticaRESUMEN
OBJECTIVES: To examine trends in the numbers of women and underrepresented minority (URM) pharmacy faculty members over the last 20 years, and determine factors influencing women faculty members' pursuit and retention of an academic pharmacy career. METHODS: Twenty-year trends in women and URM pharmacy faculty representation were examined. Women faculty members from 9 public colleges and schools of pharmacy were surveyed regarding demographics, job satisfaction, and their academic pharmacy career, and relationships between demographics and satisfaction were analyzed. RESULTS: The number of women faculty members more than doubled between 1989 and 2009 (from 20.7% to 45.5%), while the number of URM pharmacy faculty members increased only slightly over the same time period. One hundred fifteen women faculty members completed the survey instrument and indicated they were generally satisfied with their jobs. The academic rank of professor, being a nonpharmacy practice faculty member, being tenured/tenure track, and having children were associated with significantly lower satisfaction with fringe benefits. Women faculty members who were tempted to leave academia for other pharmacy sectors had significantly lower salary satisfaction and overall job satisfaction, and were more likely to indicate their expectations of academia did not match their experiences (p<0.05). CONCLUSIONS: The significant increase in the number of women pharmacy faculty members over the last 20 years may be due to the increased number of female pharmacy graduates and to women faculty members' satisfaction with their careers. Lessons learned through this multi-institutional study and review may be applicable to initiatives to improve recruitment and retention of URM pharmacy faculty members.
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Docentes , Satisfacción en el Trabajo , Grupos Minoritarios/psicología , Facultades de Farmacia , Mujeres , Educación en Farmacia/tendencias , Femenino , Humanos , Facultades de Farmacia/tendencias , Encuestas y Cuestionarios , Mujeres/psicologíaRESUMEN
BACKGROUND: In 2003, the World Health Organization reported that 50% of patients are adherent to long-term therapies. Frequently, the reason for a patient's nonadherence is the cost of medications. Even with prescription insurance coverage, patients may not be able to afford their medications. OBJECTIVE: To assess prescriber knowledge of the cost of commonly prescribed medications including atorvastatin, gabapentin, levofloxacin, losartan, pantoprazole, pioglitazone, and quetiapine. Secondary objectives were to evaluate how often prescribers consult a discounted drug list and a patient's prescription insurance coverage. METHODOLOGY: One hundred prescribers from the Medical University of South Carolina were surveyed from November 2010 to January 2011. Prescribers consisted of medical residents, attending physicians, fellows, nurse practitioners, and physician assistants. Wholesale prices of medications were determined using the Red Book, and prescription insurance prices were calculated from an average of the top 3 prescription insurance companies' copayments. RESULTS: Medical residents made up 72% of those surveyed, fellows 3%, attending physicians 12%, physician assistants 3%, and nurse practitioners 10%. The prescriber groups were unable to correctly determine the cost of medications of more than 50% of total possible responses. The majority of prescribers rarely asked about a patient's prescription insurance coverage or consulted a discounted drug list before writing a prescription. CONCLUSIONS: Prescribers are more likely to know the cost of medications for patients who have prescription insurance coverage versus those who do not.
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Personal de Salud , Pautas de la Práctica en Enfermería , Pautas de la Práctica en Medicina , Medicamentos bajo Prescripción/economía , Honorarios por Prescripción de Medicamentos , Humanos , Seguro de Servicios Farmacéuticos/economía , Cooperación del PacienteRESUMEN
Several single-center studies have suggested that higher doses of vancomycin, aimed at producing trough concentrations of >15 mg/liter, are associated with increased risk of nephrotoxicity. We prospectively assessed the relative incidence of nephrotoxicity in relation to trough concentration in patients with documented methicillin-resistant Staphylococcus aureus (MRSA) infections at seven hospitals throughout South Carolina. Adult patients receiving vancomycin for at least 72 h with at least one vancomycin trough concentration determined under steady-state conditions were prospectively studied. The relationship between vancomycin trough concentrations of >15 mg/ml and the occurrence of nephrotoxicity was assessed using univariate and multivariate analyses, controlling for age, gender, race, dose, length of therapy, use of other nephrotoxins (including contrast media), intensive care unit (ICU) residence, episodes of hypotension, and comorbidities. Nephrotoxicity was defined as an increase in serum creatinine of 0.5 mg/dl or a ≥ 50% increase from the baseline for two consecutive measurements. MICs of vancomycin for the MRSA isolates were also determined. A total of 288 patients were studied between February 2008 and June 2010, with approximately one-half having initial trough concentrations of ≥ 15 mg/ml. Nephrotoxicity was observed for 42 patients (29.6%) with trough concentrations >15 mg/ml and for 13 (8.9%) with trough concentrations of ≤ 15 mg/ml. Multivariate analysis revealed vancomycin trough concentrations of >15 mg/ml and race (black) as risk factors for nephrotoxicity in this population. Vancomycin trough concentrations of >15 mg/ml appear to be associated with a 3-fold increased risk of nephrotoxicity.
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Antibacterianos , Enfermedades Renales/epidemiología , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Infecciones Estafilocócicas/tratamiento farmacológico , Vancomicina , Adulto , Anciano , Antibacterianos/efectos adversos , Antibacterianos/sangre , Creatinina/sangre , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , Femenino , Hospitales/estadística & datos numéricos , Humanos , Incidencia , Enfermedades Renales/inducido químicamente , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , South Carolina/epidemiología , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/microbiología , Resultado del Tratamiento , Vancomicina/efectos adversos , Vancomicina/sangreRESUMEN
Aldosterone is a mineralocorticoid hormone synthesized by the adrenal glands that has several regulatory functions to help the body maintain normal volume status and electrolyte balance. Studies have shown significantly higher levels of aldosterone secretion in patients with congestive heart failure compared with normal patients. Elevated levels of aldosterone have been shown to elevate blood pressure, cause left ventricular hypertrophy, and promote cardiac fibrosis. An appreciation of the true role of aldosterone in patients with chronic heart failure did not become apparent until the publication of the Randomized Aldactone Evaluation Study. Until recently, the use of aldosterone receptor antagonists has been limited to patients with severe heart failure and patients with heart failure following myocardial infarction. The Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) study added additional evidence to support the expanded use of aldosterone receptor antagonists in heart failure patients. The results of the EMPHASIS-HF trial showed that patients with mild-to-moderate (New York Heart Association Class II) heart failure had reductions in mortality and hospitalizations from the addition of eplerenone to optimal medical therapy. Evidence remains elusive about the exact mechanism by which aldosterone receptor antagonists improve heart failure morbidity and mortality. The benefits of aldosterone receptor antagonist use in heart failure must be weighed against the potential risk of complications, ie, hyperkalemia and, in the case of spironolactone, possible endocrine abnormalities, in particular gynecomastia. With appropriate monitoring, these risks can be minimized. We now have evidence that patients with mild-to-severe symptoms associated with systolic heart failure will benefit from the addition of an aldosterone receptor antagonist to the standard therapies of angiotensin-converting enzyme inhibitors and beta-blockers. This review will address the pharmacologic basis of aldosterone receptor antagonists in patients with heart failure and the clinical impact of this therapy.
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Aldosterona/metabolismo , Fármacos Cardiovasculares/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Antagonistas de Receptores de Mineralocorticoides , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Fármacos Cardiovasculares/efectos adversos , Enfermedad Crónica , Insuficiencia Cardíaca/metabolismo , Humanos , Antagonistas de Receptores de Mineralocorticoides/efectos adversos , Selección de Paciente , Receptores de Mineralocorticoides/metabolismo , Medición de Riesgo , Resultado del TratamientoRESUMEN
Benchmarking in academic pharmacy, and recommendations for the potential uses of benchmarking in academic pharmacy departments are discussed in this paper. Benchmarking is the process by which practices, procedures, and performance metrics are compared to an established standard or best practice. Many businesses and industries use benchmarking to compare processes and outcomes, and ultimately plan for improvement. Institutions of higher learning have embraced benchmarking practices to facilitate measuring the quality of their educational and research programs. Benchmarking is used internally as well to justify the allocation of institutional resources or to mediate among competing demands for additional program staff or space. Surveying all chairs of academic pharmacy departments to explore benchmarking issues such as department size and composition, as well as faculty teaching, scholarly, and service productivity, could provide valuable information. To date, attempts to gather this data have had limited success. We believe this information is potentially important, urge that efforts to gather it should be continued, and offer suggestions to achieve full participation.