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Improving Medication Adherence in HIV

Since the introduction of antiretroviral therapy more than a decade ago, morbidity and mortality among patients infected with HIV has decreased considerably thanks to improved access to care, prophylaxis against opportunistic infections, and medications. In the September 1, 2009 issue of Clinical Infectious Diseases, guidelines were released to assist clinicians managing this infection. They provide information on patient management as well as medication adherence, and can assist clinicians in all stages of HIV management. Judith A. Aberg, MD, who was on the guideline panel that was created by the HIV Medicine Association of the Infectious Diseases Society of America, says “once therapy has been initiated, the response to therapy should be monitored 4 to 8 weeks later with a repeated virus load determination.” CD4 cell counts should be followed both for assessment of antiretroviral efficacy and to determine the need for prophylaxis against opportunistic infections. A Multipronged Approach to Adherence In the December 8, 2009 Journal of the American College of Cardiology, my colleagues and I conducted a study in which we compared outcomes in 2,868 patients who underwent PCI for ACS just prior to enrollment in the PROVE IT–TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis In Myocardial Infarction 22) trial. The PROVE IT–TIMI 22 randomized ACS patients to either 80 mg atorvastatin or 40 mg pravastatin daily. Of the original cohort, 69% had undergone PCI just prior to randomization. The incidence of the primary composite end point of all-cause mortality, myocardial infarction, unstable angina leading to hospitalization, and revascularization after 30 days and stroke was evaluated. We also assessed the incidence of TVR and non-TVR during...

A New Approach to Reducing the HAI Burden

The prevention of hospital-acquired infections (HAIs)—particularly bloodstream infections (BSIs) and ventilator-associated pneumonia (VAP)—has become a focus of critical care and a marker for quality among ICUs due to their significant burden. Under rules created by the CMS, a catheter-related BSI (CR-BSI) is now considered one of the preventable complications that will not be incrementally reimbursed. As a result, hospitals are more closely scrutinizing rates of HAIs and increasingly making efforts to reduce their impact. Assessing Potential Strategies In the March 2010 Archives of Surgery, my colleagues and I published a retrospective analysis of data collected 6 months before and after institution of a chlorhexidine gluconate bathing protocol in a trauma ICU. Chlorhexidine is an antiseptic preparation that has demonstrated broad activity against yeasts, viruses, and bacteria (including multi-drug resistant organisms, such as MRSA and Acinetobacter baumannii). The study compared the efficacy of daily bathing with washcloths impregnated with 2% chlorhexidine with that of disposable washcloths without this substance to determine the effect on HAI rates as well as its effect on the rate of isolation of multidrug-resistant organisms. “Using routine decontamination bathing regimens may help decrease the potential for organism transmission.” We observed that introduction of 2% chlorhexidine gluconate to routine, daily whole-body bathing of trauma ICU patients was associated with a significant reduction in the incidence of CR-BSIs. While the incidence of VAP was not significantly affected by chlorhexidine baths, patients who received these baths were less likely to develop MRSA VAP. The rate of colonization with MRSA and Acinetobacter was significantly lower in the chlorhexidine group than in the comparison group. The intervention also appeared to change...

Distal Radius Fractures: New Guidelines

Distal radius fractures are among the most common fractures in the body, usually occurring as a result of a fall. The radius is the most commonly broken bone in the arm. Typically, these breaks occur when a person’s fall causes them to land on outstretched hands. Among younger people, distal radius fractures may occur via car, bicycle, and skiing accidents as well as other similar situations. Older individuals are at increased risk for these fractures if they have osteoporosis. Distal radius fractures in people aged 60 and older are frequently caused by falls from a standing position. Their decreased bone density can make relatively minor falls result in broken wrists. According to the American Academy of Orthopaedic Surgeons (AAOS), more than 261,000 emergency room visits in 2007 were caused by distal radius fractures. “These fractures are most commonly seen and treated in emergency departments, but follow-up of these patients is typically performed by primary care providers and orthopedic surgeons,” explains David M. Lichtman, MD. “Currently, there are many treatment options for managing patients with distal radius fractures, ranging from less invasive methods, such as cast treatment, to more invasive techniques, such as fixation devices. Physicians are often challenged by treatment decisions because there is relatively little evidence-based information to guide them along the way.”  A Deeper Look at the Evidence In December 2009, the AAOS approved and released an evidence-based clinical practice guideline on the treatment of distal radius fractures. Available at www.aaos.org, it analyzed over 4,000 journal articles from around the world over 1 year. Each article was graded on a 5-point scale depending on strength and quality...

American Society of Clinical Oncology 2010

The American Society of Clinical Oncology, or ASCO, held its 2010 annual meeting from June 4 to 8 in Chicago. The features below highlight some of the news emerging from the meeting. » A New Screening Strategy for Ovarian Cancer » Yoga Improves Sleep in Cancer Survivors » Genetics, Heart Disease, & Dosing of Chemotherapy » Maintenance Therapy May Cut Risk of Lymphoma Recurrence A New Screening Strategy for Ovarian Cancer [back to top] The Particulars: More than 70% of ovarian cancers are diagnosed when they have already grown to an advanced stage. There are currently no effective screening tools for the early detection of ovarian cancer in women at average risk. A screening strategy that incorporated change of CA-125 levels over time and age of the participant was assessed to estimate the risk of ovarian cancer using the Risk of Ovarian Cancer Algorithm (ROCA), followed by transvaginal sonography (TVS). Data Breakdown: : In an analysis of 3,238 women who participated in the 8-year study, researchers found that the combined specificity of ROCA followed by TVS for referral to surgery was 99.7%. The average annual rate of referral to 3 monthly CA-125 screenings was 6.8%, and the average annual rate of TVS and gynecologic oncology referral was 0.9%. Cumulatively, 85 women received TVS and referral to a gynecologic oncologist. Eight women subsequently underwent surgery based on the TVS and referral, with three invasive ovarian cancers, two borderline ovarian tumors, and three benign ovarian tumors, providing a positive predictive value of 37.5%. Less than 1% of participants annually required a TVS. The invasive high-grade ovarian cancers that were detected were...

Improving Quality of Life for Migraineurs

One of the unmet needs of the migraine population is the identification of individuals who actively require treatment. When migraine is left untreated or inadequately treated, increased medical costs and decreased productivity result. Of the roughly 25 to 30 million Americans with active migraine, around 6 million have the chronic variant, meaning they have suffered headaches at least 15 days per month for at least 3 consecutive months. Chronic migraine accounts for a disproportionate share of the economic burden associated with migraine generally. Prevention or suppression of headaches associated with chronic migraine assumes paramount importance. It can be challenging for physicians to choose the most appropriate therapy for treating migraine, and there are many issues to consider when determining the most appropriate management strategies. Clinicians must ask themselves if their patients are in need of acute therapy only or prophylactic therapy in addition to acute therapy. Although guidelines are available to assist clinicians in prescribing prophylactic therapy, treatment needs and responses vary from patient to patient. Arriving at an effective treatment regimen may take time, and patients should be warned not to expect instant success. A commitment from patients to adhere to prescribed treatment strategies typically will be required to achieve a successful outcome. Open communication between providers and patients and the provision of educational materials are essential to fostering positive outcomes. Ensuring Adherence The importance of patient education cannot be overestimated. My colleagues and I have conducted studies in which migraineurs attended a headache school taught by lay instructors. Patients who received this type of education—which focused on the biology of migraine as well as acute and chronic...

Measuring Preventable Harm

Although the healthcare community has expressed a strong desire to measure safety outcomes, accomplishing this feat has been challenging due to poor investment in the basic science of patient safety. There is a need for basic science because it can allow for better understanding of the causes of harm, help in designing and pilot testing interventions to reduce harm, and enable researchers to evaluate the effects of harm. To advance the science of measuring safety outcomes, it’s critical to separate and distinguish preventable harm from inevitable harm. In healthcare, the term preventable harm differs substantially from that in other industries. Despite receiving evidence-based medical therapies, some patients will inevitably die or sustain complications and problems that are preventable are likely to change over time. It’s important to consider strategies that tease apart preventable harm from inevitable harm, such as: Assuming all harm is preventable (high sensitivity, low specificity). Adjusting for preventability (low sensitivity, low specificity). Linking care received to outcomes (high specificity, low sensitivity). Assessing Potential Strategies Virtually all harm has been labeled as inevitable for decades by clinicians, but recent efforts by payers (eg, CMS) have aimed to label all harm as preventable. This strategy could be appropriate when evidence suggests that most harmful events are preventable. However, the problem is most measures of harm are missing one or several of the required validity components. Most harms are preventable to some degree, but we don’t have evidence to tell us how much. Another strategy could be to use risk-adjustment models to account for preventable and inevitable harm. Such models typically adjust for severity of illnesses, patient demographics, comorbid...

The American Psychiatric Association 2010 Annual Meeting

The American Psychiatric Association held its 2010 annual meeting from May 22 to 26 in New Orleans. The features below highlight some of the news emerging from the meeting. » A Strategy to Improve PTSD Outcomes » Assessing Body Image in Anorexia Nervosa » New Insights on Opioid Dependence » Spotting College Depression With E-Mail » Does Bipolar Disorder Increase Hypertension Risks? A Strategy to Improve PTSD Outcomes The Particulars: Randomized controlled trials have shown that sertraline, an SSRI, and prolonged exposure (PE) are effective treatments for PTSD, but these treatment strategies are very different from each other. With PE, patients are encouraged to directly approach their trauma memories and trauma-related fears. With SSRI use, a level of engagement with trauma-related stimuli is not required. Data Breakdown: In a doubly randomized preference trial, researchers compared SSRI use and PE use and assessed efficacy for chronic PTSD and how patient preference for one strategy over the other may influence the treatment effect. Overall, both PE and SSRI interventions demonstrated good efficacy. Patients who had no choice in their treatment had more diminished effects. Response rates were higher among patients who had a choice (80%) as compared with a 55% rate for patients who were not allowed to choose their treatment. Patients who did not receive their preferred treatment tended to have more severe PTSD, as well as depression and anxiety. Take Home Pearls: Outcomes for patients with PTSD appear to improve when patient preference is taken into account as treatments are prescribed. Treatment with SSRIs and treatment via PE were both effective, but outcomes were optimized among patients who received...

Adopting Aldosterone Antagonist Therapy

Randomized clinical trials on the use of aldosterone antagonists in eligible patients with heart failure have shown an incremental 15% to 30% reduction in all-cause mortality. They also have been associated with a substantial risk reduction in the likelihood of rehospitalization or first-time hospitalizations for heart failure. Due to robust supporting data, aldosterone antagonists have been advised as Class I recommendations in the American College of Cardiology/American Heart Association (AHA) guidelines since 2005 for individuals with moderate-to-severe heart failure and for those with post-myocardial infarction left ventricular dysfunction. Slow Adoption of Evidence-Based Therapy Despite data supporting its efficacy, adoption of aldosterone antagonist therapy for the treatment of heart failure in eligible patients has been slow. In the October 21, 2009 JAMA, my colleagues and I published an observational analysis among patients who were admitted with heart failure in 241 participating hospitals in the AHA’s Get With the Guidelines—Heart Failure (GWTG-HF) quality improvement program. This national quality improvement program was designed to promote adherence to guideline-based recommendations. The GWTG-HF program tracked aldosterone antagonist therapy use, indications, contraindications, and laboratories of 43,000 patients hospitalized with heart failure during the study timeframe. Results demonstrated that: Less than one-third of heart failure patients eligible for aldosterone antagonist therapy (and without documented contraindications) were treated. Prescription of aldosterone antagonists at discharge varied widely among hospitals. Appropriate use of aldosterone antagonist therapy was less common among the elderly; Caucasians; those with lower systolic blood pressure; those without implantable cardioverter-defibrillators or pacemakers; those without a history of alcohol use or depression; and those with a history of renal insufficiency. Rates of inappropriate use were infrequent. Concerns...

Catching the Warning Signs of DVT

In the United States, more people die each year from pulmonary embolism (PE) than motor vehicle accidents, breast cancer, or AIDS. Most PEs are complications of deep vein thrombosis (DVT). In fact, more than 2 million Americans suffer from DVT each year, with over half of these individuals developing their DVT complications in the hospital or in the 30 days after hospitalization. While the connection between the risk of DVT, cancer, and cancer treatment is not fully understood, the literature suggests that approximately 10% of individuals who present with DVT or PE will have a cancer diagnosis within 2 years of the thrombotic episode. Other factors that increase the risk of DVT in patients with cancer are those whose disease has metastasized and those who are receiving chemotherapy. Furthermore, it has been reported that the probability of death within about 6 months of initial hospital admissions is over 94% for those who had venous thromboembolism and malignant disease compared with a rate of less than 40% for those with cancer alone. What Oncology Nurses Can Do From an historical perspective, DVT has been more closely related to surgical conditions. As such, routine attention to DVT risk has been given primarily to surgical patients; these individuals would be given compression stockings, prophylaxis, or other treatment. Now, there is heightened awareness that medical patients are also at risk for DVT. In addition to a cancer diagnosis, multiple risk factors and triggering events are associated with DVT, including increasing age, immobility, stroke, paralysis, previous DVT, major surgery, trauma, obesity, and inherited clotting predisposition, among others. Oncology nurses should be aware of risk...
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