Effie L. Gillespie

Impact of Prophylactic Postoperative β-Blockade on Post-Cardiothoracic Surgery Length of Stay and Atrial Fibrillation

BACKGROUND Previous studies have shown that post-cardiothoracic surgery atrial fibrillation (AF) increases the risk of hospital length of stay (LOS), overall mortality, pulmonary edema, and need for a balloon pump. A meta-analysis of 2 previous trials showed a nonsignificant reduction in LOS with postoperative β-blockers but only encompassed 1200 patients, with few valve surgery patients, and neither study used a hospital within the US. OBJECTIVE To evaluate the impact of postoperative β-blockers on LOS and AF. Secondary endpoints of overall mortality, pulmonary edema, and need for an intra-aortic balloon pump (IABP) were also evaluated between groups. METHODS This was a prospective cohort evaluation of all patients undergoing cardiothoracic surgery at our institution between October 1999 and October 2003. Patients receiving prophylactic postoperative β-blockers were matched (1:1) with patients not receiving prophylaxis for age >70 years, valvular surgery, history of AF, gender, and use of preoperative digoxin and β-blockers. RESULTS Patients (n = 1660) receiving postoperative β-blockade had a reduction in LOS (mean ± SD 10.22 ± 11.38 vs 12.40 ± 15.67; p = 0.001) and AF (23.5% vs 28.4%; p = 0.02). Mortality, pulmonary edema, and need for IABP were reduced by >50% (p < 0.001; p = 0.001; p < 0.001, respectively), while myocardial infarction and stroke were not significantly impacted. CONCLUSIONS In this observational cohort study, prophylactic postoperative β-blocker use was associated with shorter hospital LOS by an average of 2.2 days and a 17.3% lower incidence of AF. It may also be associated with reductions in overall mortality, pulmonary edema, and need for an IABP.

The impact of gender on survival amongst patients with implantable cardioverter defibrillators for primary prevention against sudden cardiac death

Background.  Implantable cardioverter defibrillators (ICDs) are a life‐saving therapy for many patients with cardiovascular disease at increased risk of fatal dysrhythmias. As men comprise the majority of the study population (67–92%) in clinical trials, the benefit to women is unknown. We performed a meta‐analysis of primary prevention trials to evaluate the impact of ICDs in men and women on death from any cause.

Impact of prophylactic amiodarone on length of hospital stay, stroke, and atrial fibrillation after cardiothoracic surgery.

Study Objective. To evaluate the effect of prophylactic amiodarone on length of stay (LOS), postoperative stroke, and postoperative atrial fibrillation (POAF).

Probable Topical Permethrin‐Induced Neck Dystonia

A 28‐year‐old Caucasian man who applied topical 5% permethrin cream once for the treatment of scabies infestation experienced a severe dystonic reaction on the left side of his neck. Assessment of causality using the Naranjo algorithm revealed a probable relationship between this adverse drug event and application of topical permethrin. Dystonic or musculoskeletal adverse reactions, including muscle spasms, have been reported with pyrethroid insecticides only after inappropriate occupational dermal exposure. These reported reactions occurred 4–48 hours after exposure and lasted from a few days to a few weeks. The mechanism behind these adverse effects may be related to permethrins ability to delay sodium channel closure within nerve cells. This may result in a lowered threshold of nerve fibers to activation of further action potentials, leading to repetitive firing and hyperexcitation of the nervous system. Clinicians should be aware of this rare but potential adverse effect of permethrin.

Pharmacodynamics of antimicrobials: treatment optimisation

As bacterial resistance continues to increase, optimising the potential for successful clinical outcomes with antimicrobial therapy requires consideration of pharmacodynamic concepts in order to maximise bacterial eradication and minimise the potential for further resistance. Based on the pharmacodynamic characteristics of specific antibiotics, dosage modifications can be implemented to improve the likelihood of bactericidal exposure. Considering their concentration-dependent bactericidal activity, aminoglycosides benefit from increased dosages and infrequent administration, so as to achieve a maximum concentration/minimum inhibitory concentration (MIC) of 10 – 12. In contrast, β-lactams are concentration-independent killers and benefit greatest by increasing the time above the MIC (T > MIC). This can be accomplished with the use of prolonged or continuous infusion. By optimising pharmacodynamic parameters with these methodologies, successful treatment of pathogens may be possible in patient populations for whom standard dosing regimens are not effective.

Cost‐Effectiveness of Amiodarone for Prophylaxis of Atrial Fibrillation After Cardiothoracic Surgery

Study Objective. To determine whether prophylactic amiodarone, dosed according to Atrial Fibrillation Suppression Trial (AFIST) I and II regimens, is a cost‐effective strategy for prevention of postoperative atrial fibrillation.

Cost-Effectiveness Analysis of Combination Statin/Ezetimibe Therapy for the Treatment of Elevated Low-Density Lipoprotein Cholesterol

Purpose Although statins have been shown to reduce LDL-C and coronary heart disease risk, it is not uncommon for patients to fail to reach NCEP ATP III goals. Some statins cannot lower LDL-C sufficiently; others cannot be titrated optimally due to drug interactions and adverse effects. Concomitant ezetimibe administration can augment LDL-C reduction over statin monotherapy; however, multidrug therapy may result in additional expense. Methods We conducted a cost-effectiveness analysis (CEA) from the hospital perspective including all FDA approved statins alone (fluvastatin, lovastatin, pravastatin, simvastatin, rosuvastatin, or atorvastatin) or the following statins plus ezetimibe: lovastatin, pravastatin, simvastatin, or atorvastatin. LDL-C lowering efficacy was determined from clinical trials. Our institutions actual acquisition cost was used to approximate drug cost (US

The impact of ACE inhibitors or angiotensin II type 1 receptor blockers on the development of new-onset type 2 diabetes.

2,004) for each statin dose alone and with ezetimibe. To test the robustness of our results a Monte Carlo simulation was conducted varying both the cost of drug and percent LDL-C reduction efficacy. Results For patients requiring less than or equal to 40% reduction from baseline in LDL-C, lovastatin 10, 20, or 40 mg, or fluvastatin 80 mg would appear to be reasonable choices based upon both efficacy and cost data. For reductions in LDL-C in the range of greater than 40%; simvastatin 40 mg plus ezetimibe 10 mg was found to be most cost effective; although, simvastatin 80 mg, rosuvastatin 20 or 40 mg, or simvastatin 80 mg plus ezetimibe 10 mg appear to be reasonably cost-effective as well. These results were not found to be robust to variations in drug cost and LDL-C reduction. Conclusion When smaller reductions in LDL-C are required (less than 40%), drug cost is the variable that most significantly drives cost effectiveness; however, when larger LDL-C reductions are required, LDL-C lowering capacity is the single most important factor in determining cost-effectiveness of the lipid-lowering therapies. The addition of ezetimibe becomes most cost-effective when larger reductions are required.