Review Article : Sacubitril/valsartan use for the hospitalist

The mainstays of therapy for heart failure with reduced ejection fraction (HFrEF) have traditionally been angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), beta-blockers, aldosterone receptor antagonists, and diuretics for symptomatic relief (1). With few advances made over the past few decades, the principles of treating HFrEF have been revolutionized following the results of the PARADIGM-HF trial (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) in 2014. The trial compared the novel agent sacubitril/valsartan (Entresto(R)) to Enalapril (1). Sacubitril/valsartan is a combination angiotensin II receptor blocker-neprilysin inhibitor (ARNI) that replaces traditional ACEI and ARB therapy in the treatment of HFrEF. The PARADIGM-HF trial was stopped early due to overwhelming evidence of decreased mortality and decreased HFrEF related hospitalizations with sacubitril/valsartan when compared to Enalapril (2). Since the study was released, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA) released updated guidelines in May 2016. Sacubitril/valsartan now holds a Class I Recommendation for the treatment of HFrEF in patients with New York Heart Association (NYHA) class II or III heart failure (3). These recommendations were further upheld in the recently released 2017 ACC/AHA/HFSA Focused Update for the Management of Heart Failure (4).Includes bibliographical reference

The Malaria Testing and Treatment Market in Kinshasa, Democratic Republic of the Congo, 2013

Background The Democratic Republic of Congo (DRC) is one of the two most leading contributors to the global burden of disease due to malaria. This paper describes the malaria testing and treatment market in the nation’s capital province of Kinshasa, including availability of malaria testing and treatment and relative anti-malarial market share for the public and private sector. Methods A malaria medicine outlet survey was conducted in Kinshasa province in 2013. Stratified multi-staged sampling was used to select areas for the survey. Within sampled areas, all outlets with the potential to sell or distribute anti-malarials in the public and private sector were screened for eligibility. Among outlets with anti-malarials or malaria rapid diagnostic tests (RDT) in stock, a full audit of all available products was conducted. Information collected included product information (e.g. active ingredients, brand name), amount reportedly distributed to patients in the past week, and retail price. Results In total, 3364 outlets were screened for inclusion across Kinshasa and 1118 outlets were eligible for the study. Among all screened outlets in the private sector only about one in ten (12.1%) were stocking quality-assured Artemisinin-based Combination Therapy (ACT) medicines. Among all screened public sector facilities, 24.5% had both confirmatory testing and quality-assured ACT available, and 20.2% had sulfadoxine-pyrimethamine (SP) available for intermittent preventive therapy during pregnancy (IPTp). The private sector distributed the majority of anti-malarials in Kinshasa (96.7%), typically through drug stores (89.1% of the total anti-malarial market). Non-artemisinin therapies were the most commonly distributed anti-malarial (50.1% of the total market), followed by non quality-assured ACT medicines (38.5%). The median price of an adult quality-assured ACT was $6.59, and more expensive than non quality-assured ACT ($3.71) and SP ($0.44). Confirmatory testing was largely not available in the private sector (1.1%). Conclusions While the vast majority of anti-malarial medicines distributed to patients in Kinshasa province are sold within the private sector, availability of malaria testing and appropriate treatment for malaria is alarmingly low. There is a critical need to improve access to confirmatory testing and quality-assured ACT in the private sector. Widespread availability and distribution of non quality-assured ACT and non-artemisinin therapies must be addressed to ensure effective malaria case management