Severe Hyperosmolar Metabolic Acidosis Due to a Large Dose of Intravenous Lorazepam

This is the publisher's version, also available electronically from http://www.nejm.org/doi/full/10.1056/NEJM200204183461618.No abstract is available for this item

COST-EFFECTIVENESS OF INTRAVENOUS NICARDIPINE VERSUS SODIUM NITROPRUSSIDE FOR POSTOPERATIVE HYPERTENSION AFTER CARDIAC SURGERY.

Postoperative hypertension after cardiac surgery is common and associated with substantial morbidity. Both sodium nitroprusside (SNP) and nicardipine (NIC) are effective in its management. SNP is inexpensive, but associated with labile blood pressure (BP) control, cardiac ischemia, and metabolite toxicity. NIC is well tolerated and provides stable BP control, but is limited by high acquisition cost. We conducted a cost-effectiveness analysis from an institutional perspective of NIC versus SNP in subjects experiencing postoperative hypertension after cardiac surgery. A retrospective, cohort study identified subjects who underwent coronary artery bypass grafting (CABG) and/or valve surgery at our institution between 2007-2009. We included adults experiencing postoperative hypertension requiring ≥ 30 minutes of either NIC or SNP infusions. Institutional-specific data from the Society of Thoracic Surgeons and University HealthSystem Consortium national databases and our financial and electronic medical records were used. The number of infusion rate changes divided by the infusion duration was calculated. We considered ≥ 1 dose change/hour to represent excessive dose changes and presumably uncontrolled blood pressure. The rate per 100 subjects in each group who avoided excessive dose changes served as the efficacy variable for the economic model. Direct postoperative costs were calculated. Data were compared with t, Wilcoxon Rank Sum, Chi-square, or Fisher's exact tests as appropriate. Log-binomial regression was used to control for surgery type and severity of illness. Of the 112 subjects identified, 72 received NIC and 40 SNP. Demographics including hypertension history, number of preoperative antihypertensive agents, surgery type, and postoperative length of stay were not significantly different. NIC required significantly fewer dose changes/hour (1.2±1.6) versus SNP (1.7±1.8, p=0.004). After controlling for surgery type and severity of illness, the risk of excessive dose changes was 60% higher in those subjects prescribed SNP compared to those prescribed NIC (adjusted relative risk = 1.60, 95%CI, 1.10-2.34, p=0.0147). In the entire cohort and each specific surgery type, NIC remained cost-effective when compared to SNP. NIC use may be limited due to decisions based solely upon acquisition costs. We found that NIC resulted in less frequent dose changes and was cost-effective when compared to SNP in the treatment of post-cardiac surgery hypertension

Impact of a community-based diabetes self-management program on key metabolic parameters

OBJECTIVE: Characterize the impact of a pharmacist-led diabetes self-management program on three key metabolic parameters: glycosylated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and mean arterial blood pressure (MAP) among employee health program participants. METHODS: A self-insured company in the Kansas City metropolitan area began offering a pharmacist-led diabetes self-management program to eligible company employees and their dependents in 2008. A retrospective pre-post analysis was conducted to determine if the program affected key metabolic parameters in participants by determining mean change after one year of participation. RESULTS: Among 183 program participants, 65 participants met inclusion criteria. All three key metabolic parameters were significantly reduced from baseline to one year of program participation: HbA1c decreased from 8.1% to 7.3% (p=0.007); LDL-C decreased from 108.3 mg/dL to 96.4 mg/dL (p=0.009); and MAP decreased from 96.1 to 92.3 mm Hg (p=0.005). CONCLUSIONS: The pharmacist-led diabetes self-management program demonstrated significant reductions in HbA1c, LDL-C, and MAP from baseline to one year of program participation. Improvements were statistically significant and clinically relevant for each parameter. Previous studies indicate these reductions may cause reduced overall healthcare costs

The impact of omega-3 fatty acid use on the risk of atrial fibrillation in patients with cardiovascular disease

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Nationwide antibiogram analysis using NCCLS M39-A guidelines

This is the published version, also available here: http://dx.doi.org/10.1128/JCM.43.6.2629-2634.2005.Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported 0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution

A Quantitative Genetic Analysis of the Associations Among Language Skills, Peer Interactions, and Behavioral Problems in Childhood: Results From a Sample of Twins

A body of empirical research has revealed that there are associations among language skills, peer interactions, and behavioral problems in childhood. At the same time, however, there has been comparatively less research devoted to exploring the mutual unfolding of these factors over the first few years of life. The current study is designed to partially address this gap in the literature by examining how language skills, negative peer interactions, and behavioral problems are interrelated in a sample of twins drawn from the Early Childhood Longitudinal Study–Birth Cohort (ECLS-B). Employing a quantitative genetic framework, the results of the current study revealed that variance in language skills, negative peer interactions, and externalizing behavioral problems were all due to a combination of genetic and environmental factors. Bivariate Cholesky models indicated that most of the covariance among language skills, negative peer interactions, and externalizing behavioral problems was due to common genetic factors. Additional analyses using a modified DeFries–Fulker approach nested within a path model revealed a bidirectional association between negative peer interactions and externalizing behavioral problems, wherein there appeared to be feedback loops between the two. Implications of the results are discussed and avenues for future research are offered

Community pharmacy-based medication therapy management services: financial impact for patients

This is the published version. Copyright 2012 Centro de Investigaciones y Publicaciones Farmaceuticas.Objective: To determine the direct financial impact for patients resulting from Medication Therapy Management (MTM) interventions made by community pharmacists. Secondary objectives include evaluating the patient and physician acceptance rates of the community pharmacists’ recommended MTM interventions. Methods: This was a retrospective observational study conducted at 20 Price Chopper and Hen House grocery store chain pharmacies in the Kansas City metro area from January 1, 2010 to December 31, 2010. Study patients were Medicare Part D beneficiaries eligible for MTM services. The primary outcome was the change in patient out-ofpocket prescription medication expense as a result of MTM services. Results: Of 128 patients included in this study, 68% experienced no out-of-pocket financial impact on their medication expenses as a result of MTM services. A total of 27% of the patients realized a cost-savings (USD440.50 per year, (SD=289.69)) while another 5% of patients saw a cost increase in out-of-pocket expense (USD255.66 per year, (SD=324.48)). The net financial impact for all 128 patients who participated in MTM services was an average savings of USD102.83 per patient per year (SD=269.18, p<0.0001). Pharmacists attempted a total of 732 recommendations; 391 (53%) were accepted by both the patient and their prescriber. A total of 341 (47%) recommendations were not accepted because of patient refusal (290, 85%) or prescriber refusal (51, 15%). Conclusions: Patient participation in MTM services reduces patient out-of-pocket medication expense. However, this savings is driven by only 32% of subjects who are experiencing a financial impact on out-of-pocket medication expense. Additionally, the majority of the pharmacists’ recommended interventions (53%) were accepted by patients and prescribers

Sexual Orientation and Involvement in Nonviolent and Violent Delinquent Behaviors: Findings From the National Longitudinal Study of Adolescent to Adult Health

Abstract This study examined the association between sexual orientation and nonviolent and violent delinquency across the life course. We analyzed self-reported nonviolent and violent delinquency in a sample of heterosexual males (N = 5220-7023) and females (N = 5984-7875), bisexuals (N = 34-73), gay males (N = 145-189), and lesbians (N = 115-150) from the National Longitudinal Study of Adolescent to Adult Health (Add Health). The analyses revealed, in general, that bisexuals were the most delinquent of the sexual orientation categories for both males and females. Additional analyses revealed that heterosexual males reported significantly higher levels of both violent and nonviolent delinquency than gay males, whereas lesbians reported more involvement in nonviolent delinquency and, to a lesser extent, violent delinquency relative to heterosexual females. Analyses also revealed that lesbians reported significantly more delinquent behavior, particularly for nonviolent delinquency, than gay males. Future research should explore the mechanisms that account for these observed patterns and how they can be used to more fully understand the etiology of delinquency

Secondary prevention following coronary artery bypass surgery: a pilot study for improved patient education

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Evaluation of environmental scanning electron microscopy for analysis of Proteus mirabilis crystalline biofilms in situ on urinary catheters

Proteus mirabilis is a common cause of catheter-associated urinary tract infections and frequently leads to blockage of catheters due to crystalline biofilm formation. Scanning electron microscopy (SEM) has proven to be a valuable tool in the study of these unusual biofilms, but entails laborious sample preparation that can introduce artefacts, undermining the investigation of biofilm development. In contrast, environmental scanning electron microscopy (ESEM) permits imaging of unprocessed, fully hydrated samples, which may provide much insight into the development of P. mirabilis biofilms. Here, we evaluate the utility of ESEM for the study of P. mirabilis crystalline biofilms in situ, on urinary catheters. In doing so, we compare this to commonly used conventional SEM approaches for sample preparation and imaging. Overall, ESEM provided excellent resolution of biofilms formed on urinary catheters and revealed structures not observed in standard SEM imaging or previously described in other studies of these biofilms. In addition, we show that energy-dispersive X-ray spectroscopy (EDS) may be employed in conjunction with ESEM to provide information regarding the elemental composition of crystalline structures and demonstrate the potential for ESEM in combination with EDS to constitute a useful tool in exploring the mechanisms underpinning crystalline biofilm formation