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Calcium Channel Blockers Co-prescribed with Loop Diuretics: A Potential Marker of Poor Prescribing?
Woodford, HJ
Drugs & aging. 2020;(2):77-81
Abstract
Prescribing cascades are where a drug adverse reaction is wrongly attributed to the emergence of a new condition, which leads to further drug prescribing. This promotes polypharmacy, adverse drug reactions and therapeutic burden. An example of a prescribing cascade is the co-prescribing of loop diuretics to treat the peripheral oedema caused by calcium channel blocker (CCB) drugs. Although well recognised, this is still a combination of medications taken by millions of people worldwide. CCBs have no prognostic benefit in heart failure and have an absolute risk increase for oedema of around 8-18% (number needed to harm 6-13). In the treatment of hypertension, they also increase the risk of oedema and a new diagnosis of heart failure without having any major advantages over alternative drugs. The best way to manage the oedema caused by CCBs is to switch to an alternative medication. Only where this is not possible or fails to achieve therapeutic goals would the CCB-loop diuretic combination appear to be justified. In many cases, therapeutic practice could be improved by targeting people on CCB-loop diuretic combinations for medication review. This could improve quality of life and reduce polypharmacy, adverse drug reactions, therapeutic burden and financial costs for millions of people worldwide.
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2.
Screening for Atherosclerotic Cardiovascular Disease in Patients With Type 2 Diabetes Mellitus: Controversies and Guidelines.
Raggi, P
Canadian journal of diabetes. 2020;(1):86-92
Abstract
If a disease state is highly prevalent and its consequences are severe, it may be appropriate to seek methods to identify it early to forestall its development and complications. Diabetes mellitus is a proven risk factor for the development of atherosclerosis, although its face and outcome are changing, as shown in contemporary clinical trials. In fact, decompensated heart failure seems to drive the hospitalization rate in patients with diabetes, and mortality from heart failure is reduced with modern hypoglycemic treatments. Nonetheless, atherosclerotic complications continue to be a major health concern in this segment of the population and cardiovascular imaging has been employed in an attempt to achieve a more accurate risk stratification. Although imaging for detection of obstructive coronary artery disease failed to reach such a goal, imaging for preclinical atherosclerosis may be more successful. In this review, we discuss the use of computed tomography and positron emission tomography to detect preclinical coronary atherosclerosis in asymptomatic patients with diabetes. Despite recent advances in the field, several questions remain to be answered as to the ultimate benefit of imaging for prevention in diabetes mellitus.
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Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update).
Rayman, G, Vas, P, Dhatariya, K, Driver, V, Hartemann, A, Londahl, M, Piaggesi, A, Apelqvist, J, Attinger, C, Game, F, et al
Diabetes/metabolism research and reviews. 2020;:e3283
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In conjunction with advice from internal and external reviewers and expert consultants in the field, this update is based on a systematic review of the literature centred on the following: the Population (P), Intervention (I), Comparator (C) and Outcomes (O) framework; the use of the SIGN guideline/Cochrane review system; and the 21 point scoring system advocated by IWGDF/EWMA. This has resulted in 13 recommendations. The recommendation on sharp debridement and the selection of dressings remain unchanged from the last recommendations published in 2016. The recommendation to consider negative pressure wound therapy in post-surgical wounds and the judicious use of hyperbaric oxygen therapy in certain non-healing ischaemic ulcers also remains unchanged. Recommendations against the use of growth factors, autologous platelet gels, bioengineered skin products, ozone, topical carbon dioxide, nitric oxide or interventions reporting improvement of ulcer healing through an alteration of the physical environment or through other systemic medical or nutritional means also remain. New recommendations include consideration of the use of sucrose-octasulfate impregnated dressings in difficult to heal neuro-ischaemic ulcers and consideration of the use of autologous combined leucocyte, platelet and fibrin patch in ulcers that are difficult to heal, in both cases when used in addition to best standard of care. A further new recommendation is the consideration of topical placental derived products when used in addition to best standard of care.
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4.
Episodic Migraine Comorbidities: Avoiding Pitfalls and Taking Therapeutic Opportunities.
Klenofsky, B, Pace, A, Natbony, LR, Sheikh, HU
Current pain and headache reports. 2019;(1):1
Abstract
Migraine is a common neurologic disorder. This article will discuss a few factors that influence migraine (mostly episodic) and its treatment, such as sleep, obstructive sleep apnea (OSA), obesity, and affective disorders, as well as autoimmune diseases. Practitioners must be aware of these coexisting conditions (comorbidities) as they affect treatment. It is noted in literature that both the quantity (too much or too few hours) and the quality (OSA related) of sleep may worsen migraine frequency. An associated risk factor for OSA, obesity also increases migraine frequency in episodic migraine cases. A bidirectional relationship with migraine along with depression and anxiety is debated in the literature. Retrospective cohort studies are undecided and lack statistical significance, but prospective studies do show promising results on treatment of anxiety and depression as a means of improving migraine control. Finally, we address the topic of autoimmune diseases and migraine. While few studies exist at this time, there are cohort study groups looking into the association between rheumatoid arthritis, hypothyroidism, and antiphospholipid antibody. There is also evidence for the link between migraine and vascular diseases, including coronary and cerebral diseases. We suggest that these comorbid conditions be taken into account and individualized for each patient along with their pharmaceutical regimen. Physicians should seek a multifactorial treatment plan including diet, exercise, and healthy living to reduce migraine frequency.
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How Much Do Lipid Guidelines Help the Clinician? Reading Between the (Guide)lines.
Orringer, CE
Methodist DeBakey cardiovascular journal. 2019;(1):16-22
Abstract
Although lipid guidelines provide updated, practical, and clinically relevant information that may be used in patient care, the continuing publication of new evidence and the inevitable treatment gaps present in all guidelines reinforce the importance of clinical judgment in shared decision making. This article explores the development of the 2013 American College of Cardiology/American Heart Association Blood Cholesterol Guidelines and the evidence base for managing patients with severe hypercholesterolemia, provides more recent high-quality evidence, and identifies existing treatment gaps that should be considered when caring for such patients. Although it was submitted prior to publication of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol, this review also includes key takeaway messages from the updated guideline.
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Underuse of Vitamin K Antagonist and Direct Oral Anticoagulants for Stroke Prevention in Patients With Atrial Fibrillation: A Contemporary Review.
Hsu, JC, Freeman, JV
Clinical pharmacology and therapeutics. 2018;(2):301-310
Abstract
Atrial fibrillation (AF) is a leading cause of stroke. Oral anticoagulant (OAC) therapy can significantly reduce the risk of stroke in patients with AF, but underuse of OACs for stroke prevention continues to be a serious clinical problem, with significant deleterious impact on outcomes. We review the studies demonstrating OAC underutilization and evaluating strategies for promoting the increased use of OAC therapy for stroke prevention in nonvalvular AF (NVAF) patients, including in special patient populations.
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Stage of obesity epidemic model: Learning from tobacco control and advocacy for a framework convention on obesity control.
Xu, L, Lam, TH
Journal of diabetes. 2018;(7):564-571
Abstract
The 2011 United Nations political declaration against non-communicable diseases (NCDs) targeted four major risk factors: tobacco use, harmful use of alcohol, an unhealthy diet, and a lack of physical activity. The Framework Convention on Tobacco Control (FCTC), MPOWER strategies, and the four-stage model of the tobacco epidemic are useful references for the prevention and control of other risk factors and NCDs. Obesity control is a more complex challenge. Herein we propose a stage of obesity epidemic model (SOEM). Obesity is in the early stages in most countries with increasing prevalence, but its effects on mortality will increase rapidly, even if its prevalence may have reached a peak and be declining. Based on current relative risk, obesity kills one in three obese people. Like tobacco, epidemiological studies of obesity in the early stages would underestimate the risks and disease burden. Further research will reveal more harm, especially from long-term obesity since childhood. The prevalence of obesity will likely overtake smoking prevalence, but commitments to obesity control are too weak. The SOEM is needed and should be useful to forewarn against the expanding public health problems attributable to obesity, and challenges in epidemiology and interventions. Learning from tobacco control, we advocate for a framework convention on obesity control. Framing obesity control initiatives in the spirit of MPOWER strategies against tobacco should be considered to prevent and control obesity and obesity-induced diseases. Healthcare professionals should take leading roles in these initiatives and obese individuals should reduce their weight and "quit" obesity.
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Patients' and physicians' perceptions and attitudes about oral anticoagulation and atrial fibrillation: a qualitative systematic review.
Mas Dalmau, G, Sant Arderiu, E, Enfedaque Montes, MB, Solà, I, Pequeño Saco, S, Alonso Coello, P
BMC family practice. 2017;(1):3
Abstract
BACKGROUND Oral anticoagulant therapy reduces the risk of stroke in patients with atrial fibrillation, but many patients are still not prescribed this therapy. The causes of underuse of vitamin K antagonists oral anticoagulants are not clear but could be related, in part, to patients' and physicians' perceptions and attitudes towards the benefits and downsides of this treatment. The purpose of this systematic review was to evaluate and synthesize patients' and physicians' perceptions and attitudes towards the benefits and downsides of vitamin K antagonist, in order to explore potential factors related with its underuse. METHODS We included studies that used qualitative or mixed methods and focused on patients' and/or physicians' perceptions and attitudes towards oral anticoagulation. We systematically searched PubMed, EMBASE, ISI WoK, and PsycINFO from their inception until May 2013. Two reviewers independently assessed the quality of the included studies and synthesized results using a thematic analysis approach. RESULTS We included a total of nine studies. In four studies, the quality assessed was excellent and in five was moderate. We identified three themes that were of interest to both physicians and patients: information to reinforce anticoagulation use, balance of benefits and downsides, roles in decision-making and therapy management. Three additional themes were of interest to patients: knowledge and understanding, impact on daily life, and satisfaction with therapy. The main difficulties with the use of anticoagulant treatment according to physicians were the perceived uncertainty, need of individualised decision-making, and the feeling of delegated responsibility as their main concerns. The main factors for patients were the lack of information and understanding. CONCLUSION Physicians' and patients' perceptions and attitudes might be potential factors in the underuse of treatment with vitamin K antagonists. Improving the quality and usability of clinical guidelines, developing tools to help with the decision-making, enhancing coordination between primary care and hospital care, and improving information provided to patients could help improve the underuse of anticoagulation.
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9.
Premedication Use Before Infliximab Administration: A Cross-sectional Analysis.
Picoraro, J, Winberry, G, Siegel, CA, El-Matary, W, Moses, J, Grossman, A, Park, KT
Inflammatory bowel diseases. 2017;(1):174-180
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Abstract
BACKGROUND Premedications are commonly given to patients with inflammatory bowel disease before intravenous infliximab administration. We aimed to (1) describe practice variability; and (2) determine clinician rationale for premedicating patients with inflammatory bowel disease before infliximab administration. METHODS We developed a cross-sectional electronic survey after comprehensive literature review to assess practice variability and clinician rationale for premedication use before infliximab. An optional postsurvey quiz assessed clinicians' understanding of the available literature. The survey was distributed through members-only NASPGHAN and Crohn's and Colitis Foundation of America (CCFA) listservs and American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) web-based discussion boards. RESULTS Three hundred seventy-nine unique respondents with a 93.3% survey completion rate comprised 331 (87%) and 45 (12%) pediatric and adult gastroenterologists. Among numerous options for premedications, acetaminophen (66%) and diphenhydramine (64%) were most often given before each infliximab infusion. Only 20% did not routinely use premedications. There was heterogeneity of premedication use between gastroenterologists within the same clinical practice. Of 328 (87%) respondents who completed the knowledge assessment quiz, only 18% identified the association of diphenhydramine use with increased reaction. CONCLUSIONS There is high interpractice and intrapractice variability for premedication use before infliximab administration. Clinician rationale for premedicating patients seems to be driven by individual preference or group practice habit. Improved knowledge of the evidence may assist in decreasing overuse of premedications, particularly diphenhydramine.
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10.
Evaluation of effectiveness of survivorship programmes: how to measure success?
Halpern, MT, Argenbright, KE
The Lancet. Oncology. 2017;(1):e51-e59
Abstract
Although the number of cancer survivors has increased substantially in the past two decades, the evidence base regarding the effectiveness of cancer survivorship programmes is inadequate. Survivorship programmes tend to evaluate their effectiveness by assessing changes in patient-reported outcomes, symptoms and health status, knowledge, and receipt of cancer surveillance in programme participants. However, more comprehensive and high-quality evaluations of survivorship programmes are needed, including assessments using a broader set of measures. These expanded evaluations can include assessments of programme structure; long-term outcomes, such as survival, quality-adjusted life-years, and functional status; receipt of social support, nutritional, rehabilitative, and fertility preservation services; programme value, including costs and avoidance of inappropriate resource utilisation; and ability of programmes to increase access to needed survivorship care services and health equity. In this Series paper, we provide examples of assessment measures for currently used survivorship programmes, discuss the rationale for and potential benefits of expanded types of evaluation measures, and identify how these measures correspond to several evaluation frameworks. We conclude that use of a common, expanded set of measures to facilitate broad comparisons across survivorship programmes and thorough and systematic evaluations will help to identify the optimal programmes for individual survivors, improve outcomes, and prove the value of survivorship care.