Marion K. Slack

Amiodarone Prophylaxis for Atrial Fibrillation After Cardiac Surgery: Meta-Analysis of Dose Response and Timing of Initiation

Study Objective. To investigate a possible dose‐response relationship between amiodarone and reduction in incidence of postoperative atrial fibrillation, and to determine whether pre‐ or postoperative initiation of amiodarone is superior.

Empiric Long-term Amiodarone Prophylaxis Following Myocardial Infarction: A Meta-Analysis

BACKGROUND The prophylactic administration of amiodarone following acute myocardial infarction has been investigated in several small trials. This study combined the results of these small trials in a meta-analysis to determine the effects of prophylactic low-dose amiodarone on mortality following acute myocardial infarction. METHODS Four prospective, randomized, placebo-controlled trials, which investigated the prophylactic administration of low-dose amiodarone (200 to 400 mg/d) to patients after acute myocardial infarction, were selected from the current literature according to strict inclusion criteria. A total of 1140 patients, 566 in the amiodarone-treated group and 574 in the placebo-treated group, were included in the analysis. Sudden cardiac death, cardiac mortality, and total mortality were the end points of interest. In addition, the effect of impaired left ventricular function (ejection fraction, < 45%) on total mortality was assessed. Data were aggregated by using the Mantel-Haenszel method to obtain final summary statistics for these end points. RESULTS Patients treated with low-dose amiodarone exhibited a lower incidence of sudden cardia death (3.1%) and total mortality (6.1%) when compared with patients treated with placebo (6.9% and 11.2%, respectively; both P < .01; and 95% confidence interval [CI], 0.011 to 0.065 and 0.013 to 0.082, respectively). There was no significant difference between the amiodarone- and placebo-treated groups with respect to cardiac mortality (2.6% vs 3.7%, respectively; P = .26; and 95% CI, -0.012 to 0.032). For patients with a left ventricular ejection fraction of less than 45%, total mortality was 5.5% in the amiodarone-treated group and 9.4% in the placebo-treated group (P = .30; CI, -0.023 to 0.101). CONCLUSIONS Although further data from ongoing large, randomized trials are needed, this meta-analysis suggests that the prophylactic administration of low-dose amiodarone to patients following acute myocardial infarction reduces the incidence of both sudden cardiac death and total mortality. The benefits of low-dose amiodarone may be limited to patients with preserved left ventricular function.

Strategies used by interdisciplinary rural health training programs to assure community responsiveness and recruit practitioners

In this article, the strategies used by five US rural interdisciplinary training grant programs to respond to local needs and to promote recruitment in rural communities are described. The programs provide training to 17 health care disciplines and serve disadvantaged Hispanic, African-American, Amish, Native American, and Anglo populations. Four programs are based in academic institutions; one is based in a community health center. The programs provide services to the rural communities through individual clinical or case management services, population-level interventions, and collaborative research. All programs use specific mechanisms (e.g. case conferences or participation in local coalitions) to facilitate collaboration with residents and to link student activities with community or individual needs. Unique strategies include the use of problem-based learning and community health workers on the interdisciplinary team to increase responsiveness. The programs also provide educational support to students while they work in the rural communities. Finally, the primary strategy used to promote recruitment is the training experience in rural communities. The programs also appear to indirectly improve the environment of rural practice.

An Interdisciplinary Problem-Based Practicum in Case Management and Rural Border Health

&NA; To illustrate the application of problem‐based learning in a practicum, this article describes an interdisciplinary problem‐based practicum in case management and rural border health. Students from pharmacy, nursing, social work, and public health live and work in a rural community located on the border between the United States and Mexico. They provide case management services to pregnant women. Students conduct home visits with lay health educators, then meet in weekly case management seminars. The seminar and the interdisciplinary database are structured to support the clinical reasoning steps of data gathering, problem synthesis, hypothesis generation, and diagnostic decision making. The problembased learning approach appears to enhance student learning in a practicum setting.

Meta-analysis of the use of low-dose beta-adrenergic blocking therapy in idiopathic or ischemic dilated cardiomyopathy

We concluded that low-dose beta-adrenergic blocking agents are beneficial in the treatment of patients with ischemic or idiopathic cardiomyopathy. Low-dose beta blockers appear to improve NYHA functional class and LVEF.

Effectiveness and Safety of Non–vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation and Venous Thromboembolism: A Systematic Review and Meta-analyses

PURPOSE The findings from the observational studies comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) for atrial fibrillation (AF) and venous thromboembolism (VTE) are inconsistent. We conducted separate meta-analyses examining the efficacy/effectiveness and safety of NOACs versus VKAs by disease (AF vs VTE), study design (randomized controlled trials [RCTs] vs observational studies), and NOAC (dabigatran, rivaroxaban, apixaban, and edoxaban). METHODS The main data sources included PubMed/MEDLINE, EMBASE, Web of Science, CINAHL, and Scopus from January 1, 2005, to February 15, 2016. We searched for Phase III RCTs and observational studies comparing NOACs versus VKAs. The primary outcomes were stroke/systemic embolism (SE) for AF; recurrent VTE/fatal pulmonary embolism (PE) for VTE; and major bleeding for both conditions. Secondary outcomes included stroke and myocardial infarction (MI) for AF, recurrent deep vein thrombosis (DVT)/PE for VTE, and mortality, intracranial hemorrhage (ICH), and gastrointestinal bleeding for both conditions. Pooled hazard ratios (HRs) were reported by using inverse variance-weighted random effects models. FINDINGS A total of 13 RCTs and 27 observational studies (AF, n = 32; VTE, n = 8) were included. For AF, dabigatran and VKAs were comparable for stroke/SE risk in 1 RCT (HR, 0.77 [95% CI, 0.57-1.03]) and 6 observational studies (HR, 1.03 [95% CI, 0.83-1.27]). Rivaroxaban had a 20% decreased risk of stroke/SE in 3 RCTs (HR, 0.80 [95% CI, 0.67-0.95]) compared with VKA, but the effect was nonsignificant in 3 observational studies (HR, 0.78 [95% CI, 0.59-1.04]). Apixaban decreased stroke/systemic embolism risk (HR, 0.79 [95% CI, 0.66-0.95]) compared with VKA in 1 RCT, but edoxaban was comparable to VKA (HR, 0.99 [95% CI, 0.77-1.28]) in 1 RCT (no observational studies available for apixaban/edoxaban). Dabigatran, apixaban, and edoxaban decreased the risk of hemorrhagic stroke, mortality, major bleeding, and ICH by 10% to 71% compared with VKAs but not rivaroxaban. For VTE, NOACs and VKAs were comparable for recurrent VTE/fatal PE/DVT/PE risk in 7 RCTs and 1 observational study. The 7 RCTs demonstrated a 32% to 69% decreased risk of major bleeding for dabigatran, rivaroxaban, and apixaban compared with VKAs. No difference was shown in 1 rivaroxaban observational study (HR, 0.77 [95% CI, 0.40-1.49]) and 1 edoxaban RCT (HR, 0.84 [95% CI, 0.59-1.20]). Except for dabigatran, the NOACs had a 61% to 86% decreased risk of ICH and gastrointestinal bleeding. IMPLICATIONS Overall, NOACs were comparable or superior to VKAs. Although no observational studies are currently available for apixaban/edoxaban, a few notable inconsistencies exist for dabigatran (ischemic stroke, MI) and rivaroxaban (stroke/SE, major bleeding in VTE) between RCTs and observational studies. Individualizing NOAC/VKA therapy based on benefit/safety profiles and patient characteristics is suggested.

Drug name confusion

S 1R,-After the Gulf war the Iraqi armed forces used helicopters, bombs, and napalm to repress the Kurds and hundreds of thousands of these people (and other northern Iraqis) fled towards Turkey. Most were children, women, and old people. Besides Kurds and Muslims there were Turkomans, Arabs, and Christians. (The Turkish people recognised their fear because in 1988, 60 000 Kurds had come to Turkey after the napalm attacks on Haelepcha and 27 000 of those refugees were still living in Turkish camps.) This tragic aftermath of the Gulf war has been seen world wide. It demanded an international response. I would like to describe the

The Impact of Interdisciplinary Case Management on Client Outcomes

To assess impact, outcome data were analyzed from an interdisciplinary case management program based on the Omaha Systems model. The study population of 54 clients was 98 percent female and 98 percent Hispanic, with 65 percent having notcompleted high school. Clients averaged seven problems: 43 percent were psychosocial, 23 percent environmental, 19 percent physiological, and 15 percent health-related behaviors. Interventions (12.4/client) were primarily educational (53%) and case management (19%). Effect sizes for impact were moderate to very large (0.4 to 1.5; p <= 0.002) for knowledge, behavior, and status outcomes. The results indicate that interdisciplinary case management using the Omaha Systems model can affect significantly outcomes related to specific problems. CASE MANAGEMENT is a complex concept for which diverse definitions exist. Case management is a delivery model for providing client-focused care. 1 Key elements of the case management program include conducting a holistic, comprehensive client assessment to determine needs and capacities, developing a culturally appropriate plan of care to promote or sustain health goals, using community resources, documenting client encounters/case manager activities, monitoring/Evaluating client outcomes, and participating in intra- and interdisciplinary consultation and collaboration. 2 Core case management activities include client advocacy, coordination of care, and individualized education. 3

The Production Model as a Basis for Conducting Economic Evaluations of Regional Poison Control Centers

To identify the significant inputs, activities, and outputs of a regional poison control center, a production model is described and its potential application to the conduct of economic evaluations delineated. The model can help the researcher identify the significant inputs (costs) incurred through the provision of poison control center services. These inputs directly influence the activities that the poison center is capable of undertaking. Activities undertaken by a poison center are intermediate steps between the inputs and outputs, and serve to convert the various inputs into associated outputs. They form the basis for determining the outputs produced by the poison center services. The outputs derived from poison center services provide the conceptual framework for assessing the effectiveness of a poison center in an economic analysis. Also described are potential applications of the production model in conducting poison center cost-effectiveness and cost-benefit analyses.

Impact of Diabetes Care by Pharmacists as Part of Health Care Team in Ambulatory Settings: A Systematic Review and Meta-analysis:

Objective: To conduct a comprehensive systematic review and meta-analyses examining the impact of pharmacist interventions as part of health care teams on diabetes therapeutic outcomes in ambulatory care settings. Data Sources: PubMed/MEDLINE, EMBASE, Cochrane Library, International Pharmaceutical Abstracts, Web of Science, Scopus, WHO’s Global Health Library, ClinicalTrials.gov, and Google Scholar were searched (1995 to February 2017). Search terms included pharmacist, team, and diabetes. Study Selection: Full-text articles published in English with comparative designs, including randomized controlled trials, nonrandomized controlled trials, and pretest-posttest studies evaluating hemoglobin A1C (A1C), were assessed. Data Extraction and Synthesis: Two reviewers independently screened for study inclusion and extracted data. Quality of the studies was assessed using tools developed based on the framework of the Cochrane Collaboration’s recommendations. Data Synthesis: A total of 1908 studies were identified from the literature and reference searches; 42 studies were included in the systematic review (n = 10 860) and 35 in the meta-analyses (n = 7417). Mean age ranged from 42 to 73 years, and 8% to 100% were male. The overall standardized mean difference (SMD) for A1C for pharmacist care versus comparison was 0.57 (P < 0.01), a moderate effect representing a mean difference of 1.1% (95% CI = 0.88-1.27). The effects for systolic blood pressure and low-density lipoprotein cholesterol were between small and moderate (SMD = 0.31 and 0.32; P < 0.01). The heterogeneity was high for all outcomes (>83%), indicating functional differences among the studies. No publication bias was detected. Conclusion: Pharmacists’ interventions as part of the patient’s health care team improved diabetes therapeutic outcomes, substantiating the important role of pharmacists in team-based diabetes management.