Karen Olson

Long-term safety and efficacy of combination gemfibrozil and HMG-CoA reductase inhibitors for the treatment of mixed lipid disorders

BACKGROUND Combinations of gemfibrozil and a 3-hydroxy-3-methylglutaryl (HMG) coenzyme A reductase inhibitor show promise in treating mixed lipid abnormalities. However, concern regarding the risk of myopathy and hepatic toxicity has limited the use of this combination. To determine the long-term safety and efficacy of this combination, we prospectively identified all patients placed on a combination of gemfibrozil and any HMG reductase inhibitor. METHODS Pravastatin, simvastatin, fluvastatin, lovastatin, or atorvastatin at incremental doses was combined with gemfibrozil (600 mg twice daily). Lipid profiles, creatine kinase levels, and aminotransferase levels were monitored. Two hundred fifty-two patients with established atherosclerosis receiving combination therapy for a mean of 2.36 +/- 1.52 years spanning a total of 593.6 patient-years were monitored. RESULTS In 148 patients, gemfibrozil was started before an HMG was added. The pretreatment total cholesterol level fell from 222 +/- 34 mg/dL to 181 +/- 26 mg/dL (P <.001) on combination therapy. HDL cholesterol level rose from 30 +/- 5 mg/dL to 36 +/- 7 mg/dL (P <.01), triglyceride level fell from 361 +/- 141 mg/dL to 212 +/- 101 mg/dL (P <.03). The ratio of total cholesterol to HDL fell from 7.6 +/- 1. 7 to 5.3 +/- 1.6 (P <.001). In 104 patients an HMG was begun before gemfibrozil was added. Pretreatment total cholesterol level fell from 246 +/- 54 mg/dL to 192 +/- 40 mg/dL on combination therapy (P <.01). HDL level rose from 33 +/- 9 mg/dL to 38 +/- 9 mg/dL (P <.03) and triglyceride level fell from 314 +/- 183 mg/dL to 183 +/- 93 mg/dL (P <.001). The ratio of total cholesterol to HDL fell from 7.9 +/- 3.6 to 5.2 +/- 1.4 (P <.001). In both groups the lipid profile on combination therapy was significantly better than that obtained on single-agent therapy. One episode of myopathy (0.4%) and one episode of aminotransferase level elevation (0.4%) of greater than 3 times upper limit of normal occurred. Both resolved with cessation of therapy without consequence. CONCLUSIONS Combinations of gemfibrozil and an HMG, compared with either agent alone, results in improved long-term control of lipid abnormalities in mixed lipid disorders. The low incidence of toxicity permits the use of combination therapy in patients at high risk of atherosclerotic complications.

Two versus six hours of bed rest following left-sided cardiac catheterization and a meta-analysis of early ambulation trials

The present study and associated meta-analysis shows that 6 hours of bed rest after outpatient cardiac catheterization offers no advantage over 2 hours of bed rest with respect to groin bleeding complications. The occasional bleeding observed occurred shortly after ambulation rather than after discharge.

The Triglyceride to HDL Ratio and Its Relationship to Insulin Resistance in Pre- and Postpubertal Children: Observation from the Wausau SCHOOL Project

Insulin resistance (IR) is a risk factor for ischemic heart disease and diabetes and raises the triglyceride/high-density lipoprotein (TG/HDL) ratio in adults, but is not well defined in children. Purpose. To investigate the TG/HDL ratios in children as an IR marker. Methods. Wausau SCHOOL Project assessed 99 prepubertal and 118 postpubertal children. The TG/HDL ratio was correlated with numerous risk factors. Results. TG/HDL ratio was significantly correlated with QUICKI, HOMA-IR, zBMI, waist-to hip ratio, systolic and diastolic BP, LDL size and LDL number. A group of 32 IR children (HOMA-IR > 1 SD from the mean, i.e., >2.45) had significantly higher TG/HDL (3.11 ± 1.77) compared to non-IR children (1.86 ± 0.75). A TG/HDL ratio of ≥2.0 identified 32 of the 40 children deemed IR by HOMA-IR (>2.45) with a sensitivity of 0.80 and a specificity of 0.66. Children with TG/HDL ratio ≥3 were heavier and had higher BP, glucose, HOMA-IR, LDL number, and lower HDL level, QUICKI, and LDL size, regardless of pubertal status. Conclusion. The TG/HDL ratio is strongly associated with IR in children, and with higher BMI, waist hip ratio, BP, and more athrogenic lipid profile.

Feature topic: Clinical use of abciximab: Coronary artery stenting for suboptimal PTCA results in acute myocardial infarction in patients treated with abciximab: Early and six-month outcome

Emergent percutaneous transluminal coronary angioplasty (PTCA) is an effective treatment for acute myocardial infarction. However, occasionally results of angioplasty are suboptimal due to coronary dissection or elastic recoil, leading to a high chance of recurrent ischemia. Coronary stents are occasionally employed in such settings, but a high incidence of stent thrombosis was noted by early investigators when stents were placed into areas of active thrombus formation. Since coronary thrombosis and stent thrombosis are both initiated by platelets, the potent antiplatelet agent abciximab might be useful in preventing stent thrombosis. Little information is available concerning early outcome or 6-month clinical event rate when coronary artery stents are placed for suboptimal angioplasty results for acute myocardial infarction in patients given abciximab. We deployed 75 stents as part of angioplasty for acute myocardial infarction in 40 patients given abciximab. All patients had suboptimal angioplasty results leading to stent deployment. Each obtained normal flow angiographically and no stent thrombosis or acute closure was observed. Early mortality occurred in 1 patient. All patients were followed at least 6 months, and no patient died after hospital discharge. Three patients experienced recurrent ischemic events within the first 6 months. Two of these events were due to infarct vessel restenosis. We conclude the combined use of coronary artery stents and abciximab for suboptimal PTCA results during acute myocardial infarction is associated with a low incidence of culprit vessel recurrent ischemic events within 6 months of intervention.

Nurse leadership positions: perception vs. reality.

T hroughout the healthcare delivery system, the shortage of nurses and nurse leaders is evident.1 This shortage provides a partial explanation for the shortage of nurse leaders; however, it doesn’t fully explain why nurses aren’t pursuing these roles. According to one author, “The future of nursing leadership may be in jeopardy unless our current nursing leaders begin to build interest in this important dimension of nursing practice.”2 A 2005-2006 strategic goal of the Wisconsin Organization of Nurse Executives (W-ONE) was to lead efforts to create positive and healthy practice environments in nursing and healthcare by implementing selected recommendations from the Institute of Medicine report Keeping Patients Safe: Transforming the Work Environment of Nurses, specifically focusing on transformational leadership and evidence-based management. This report recommends that healthcare organizations should acquire nurse leaders for all levels of management and employ management structures and processes throughout the organization.3 The purpose of our study was to investigate and better understand the factors that influence nurses’ attitudes toward pursuing nursing leadership positions within hospital settings, using a large representative sample.

RANDOMIZED TRIAL OF HIGH DOSE FUROSEMIDE-HYPERTONIC SALINE IN ACUTE DECOMPENSATED HEART FAILURE WITH ADVANCED RENAL DISEASE

Randomized trials have suggested a benefit of high dose furosemide-hypertonic saline infusion (F-HSS) compared to furosemide IV bolus infusion (F-IVB) in acute decompensated heart failure (ADHF) with preserved renal function. Creatinine (CR) >2mg/dL or BUN >60mg/dL led to exclusion from published

1047-178 Low-density lipoprotein subfractions in a random sample of children and adolescents

Va sc ul ar D is ea se , H yp er te ns io n, a nd P re ve nt io n sion as a major preoperative risk factor for mortality in AAD pts. Pts bearing severe hypotension from the onset of symptoms to surgery have a worse mortality rate than those that who do not (42.3% vs 13.5%, p<0.0001). Conclusions: Our study provides information regarding the importance of preoperative hemodynamic status, from symptom onset to surgery, as a predictor of mortality in AAD pts. Knowledge about temporal variations of these parameters may help surgeons in making treatment decisions among high-risk patients being considered for potentially heroic surgical attempts.

New technique for prepping the Johnson & Johnson stent delivery system.

Current prepping of the Johnson & Johnson stent deployment balloon can be suboptimal. This simple technique allows for an improved preparation of the stent delivery balloon prior to deployment, resulting in less air in the balloon during inflation.