Ken S. Ota

The Role of Outpatient Intravenous Diuretic Therapy in a Transitional Care Program for Patients With Heart Failure: A Case Series

We present a case series of seven patients with an established diagnosis of heart failure enrolled in a transitional care program that were treated with intravenous diuretic therapy in the outpatient setting. The patients presented in this cases series were treated due to the development of decompensated heart failure within 30 days of their discharge from our hospital. All seven patients stated that they would have originally presented to the emergency department for their symptoms, but consented to alternative treatment by a transitional care physician, or transitionalist. These patients with decompensated heart failure (four male and three female) with a median age of 55 years (24 - 84 years) were evaluated and treated from November 2011 to March 2012. Of the seven patients, four presented with decompensated systolic heart failure (three with diastolic). All seven patients were treated with an intravenous diuretic for hypervolemia in our outpatient infusion room. All of the patients experienced relief of their dyspnea the day of diuretic administration or the following day. No adverse effects or emergency department transfers occurred as a result of outpatient intravenous diuretic therapy. Through the use of outpatient intravenous diuretic therapy, we have avoided the need for emergency department visits and potential hospitalization in select patients with decompensated heart failure. Based on our preliminary findings, the clinical efficacy of this approach to the treatment of heart failure decompensation is not only due to the pharmacologic effectiveness of intravenous diuretics, but also due to the bidirectional open line of communication that exists between transitionalist and patients in the program. The direct telephone access that patients have to the transitionalist allows for close post-hospitalization monitoring and facilitates timely evaluation and treatment when acute issues arise. The added benefit of our particular transitional care program is that we have an alternate venue in the hospital where our transitional care patients can be treated for heart failure decompensation (our outpatient infusion room), thus, enabling us to avoid emergency department transfers and possible hospital admissions. Further investigation of this therapy in a non-emergency department setting is warranted as our experience with this treatment modality is limited to the case series presented.

Physician-Directed Heart Failure Transitional Care Program: A Retrospective Case Review

Background Despite a variety of national efforts to improve transitions of care for patients at risk for rehospitalization, 30-day rehospitalization rates for patients with heart failure have remained largely unchanged. Methods This is a retrospective review of 73 patients enrolled in our hospital-based, physican-directed Heart Failure Transitional Care Program (HFTCP). This study evaluated the 30- and 90- day readmission rates before and after enrollment in the program. The Transitionalist’s services focused on bedside consultation prior to hospital discharge, follow-up home visits within 72 hours of discharge, frequent follow-up phone calls, disease-specific education, outpatient intravenous diuretic therapy, and around-the-clock telephone access to the Transitionalist. Results The pre-enrollment 30-day readmission rates for acute decompensated heart failure (ADHF) and all-cause readmission was 26.0% and 28.8%, respectively, while the post-enrollment rates for ADHF and all-cause readmission were 4.1% (P < 0.001) and 8.2% (P = 0.002), respectively. The pre-enrollment 90-day all-cause and ADHF readmission rates were 69.8%, and 58.9% respectively, while the post-enrollment rates for all-cause and ADHF were 27.3% (P < 0.001) and 16.4% (P < 0.001) respectively. Conclusions Our physician-implemented HFTCP reduced rehospitalization risk for patients enrolled in the program. This program may serve as a model to assist other hospital systems to reduce readmission rates of patients with HF.

Probable valproate sodium-associated hypotension

BACKGROUND Valproate sodium, a commonly used antiepileptic drug (AED), is effective for the treatment of status epilepticus and is often used as a second-line agent when other AEDs are contraindicated. Some studies have reported that infusion of valproate sodium is generally well tolerated, whereas other studies have reported various degrees of hypotension during infusion. The objective of this case report was to call attention to the potential risk of hypotension after intravenous infusion of valproate sodium. CASE SUMMARY This was the case of a 75-year-old Hispanic man (height, 145 cm; weight, 68 kg) who developed hypotension after receiving an intravenous loading dose of valproate sodium. The patient received the loading dose 12 hours after administration of his last dose of phenytoin (300 mg daily), which had been discontinued secondary to a cutaneous drug reaction. The patients medical history was significant for seizure disorder, a cerebrovascular accident, and controlled type 2 diabetes mellitus. He was taking glyburide 5 mg daily and aspirin 81 mg daily. At baseline, the patients blood pressure (measured while seated, at rest, using an upper-extremity cuff) was 135/70 mm Hg. The intravenous loading dose of valproate sodium (20 mg/kg) was administered at a rate of 14 mg/min (total dose, 1280 mg over 90 min). Approximately 2.5 hours after completion of the loading dose, the patients blood pressure decreased to 107/48 mm Hg. Because our standard operating procedure is to measure blood pressure every 4 hours after the baseline measurement, the patients hypotension was not detected during the infusion. The next morning (22 hours after completion of the valproate sodium infusion), divalproex sodium 1000 mg orally once daily was initiated as maintenance therapy. The patients blood pressure reached a nadir of 82/44 mm Hg. The hypotension was treated initially with intravenous fluid hydration with normal saline, but the blood pressure correction was transient using this approach. The patient remained hypotensive for 3 days. The hypotension was ultimately found to be self-limited, and the patient was asymptomatic throughout his hospital stay. The patients Naranjo adverse drug reaction probability scale score was 6, indicating that the relationship between valproate sodium infusion and hypotension was probable. CONCLUSION In this case report, infusion of valproate sodium at a rate of 14 mg/min was a probable cause of hypotension in a 75-year-old man.

Postdischarge transitional care management: a reimbursable service in 2013.

1. American Board of Internal Medicine, Number of First-Year Fellows by Specialty [on-line]. Available at http://www.abim.org/about/examInfo/datafellow/chart-04.aspx Accessed November 18, 2012. 2. American Medical Association and the Committee on Legislation and Advocacy, Medicare and the Sustainable Growth Rate [on-line]. Available at http://www.ama-assn.org/resources/doc/mss/cola_medicare_pres.pdf Accessed November 18, 2012. 3. American Hospital Association, American Medical Association, American Nurse Association, New Report Finds That Sequester of Medicare Spending Could Lead to More Than 750,000 Jobs Lost, September 12, 2012 Press Release [on-line]. Available at http://nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/Report-Finds-Sequester-of-MedicareSpending-Could-Lead-to-Jobs-Lost.pdf Accessed November 18, 2012.

Treatment of levator ani syndrome with cyclobenzaprine.

Objective TO report a case of levator ani syndrome (LAS) that was successfully treated with cyclobenzaprine. Case Summary A 26-year-old male presented with a 3-week history of severe, intermittent, aching anorectal pain that would last for 30–60 minutes per episode and occurred between 1 and 3 times per day. The pain was aggravated by squatting, with no alleviating factors. Physical examination revealed no prostate tenderness, lesions, hemorrhoids, or fissures and rectal tone was intact. The patient had moderate posterior rectal tenderness. After a standard workup, he was diagnosed with LAS and treated with oral cyclobenzaprine 5 mg 3 times daily for 7 days. The patient experienced resolution of his symptoms after 3 days of treatment and remained symptom-free 6 months after completion of therapy. The only reported adverse effect was mild drowsiness, which resolved after discontinuation of the cyclobenzaprine. Discussion A review of the literature via StatRef (April 1965-December 2011), Ovid (April 1965-December 2011), and MEDLINE (April 1965-December 2011) reveals that existing treatment options for LAS have been limited to levator massage, sitz baths, nonsteroidal antiinflammatory drugs, diazepam, biofeedback, botulinum toxin, steroid injections, and electrogalvanic stimulation, all of which offer minimal support. Cyclobenzaprine is a muscle relaxant; however, its mechanism of action is unclear. It is thought to influence the α and γ motor neurons in the central nervous system, which leads to the attenuation of muscle spasm. To our knowledge, cyclobenzaprine has not been reported as a treatment for LAS. In our patient, however, the clinical efficacy of cyclobenzaprine was clearly apparent. Conclusions Cyclobenzaprine effectively treated our patients LAS. Given that cyclobenzaprine is safe, inexpensive, and shown to be effective in our case study, we believe it warrants further investigation as a first-line treatment option for LAS.

Reducing Hospitalizations for Acute Decompensated Heart Failure: The Infusion Room Approach

Collins et al. ([1][1]) provide valuable insight into the complex process and current dilemmas in managing patients who present to the emergency department (ED) with acute heart failure (HF). We would like to suggest an additional venue for the management of this special population: the outpatient