Background: Chronic aortic regurgitation (AR) patients demonstrate left ventricular (LV) remodeling with increased LV mass and volume but may have a preserved LV ejection fraction (EF). We hypothesize that in chronic AR, global longitudinal systolic and diastolic function will be reduced despite a preserved LV EF. Methods: We studied with Doppler echocardiography 27 normal subjects, 87 patients with chronic AR with a LV EF > 50% (AR + PEF), 66 patients with an EF < 50% [AR + reduced LV ejection fraction (REF)] and 82 patients with hypertensive heart disease. LV volume, transmitral spectral and tissue Doppler were obtained. Myocardial velocities and their timing and longitudinal strain of the proximal and mid wall of each of the 3 apical views were obtained. Results: As compared to normals, global longitudinal strain was reduced in AR + PEF (13.8 ± 4.0%) and AR + REF (11.4 ±4.7%) vs. normals (18.4 ± 3.6%, both p < 0.001). As an additional comparison group for AR + PEF, global longitudinal strain was reduced as compared to patients with hypertensive heart disease (p = 0.032). The average peak diastolic annular velocity (e’) was decreased in AR + PEF (6.9 ± 3.3 cm/s vs. 13.4 ± 2.6 cm/s, p < 0.001) and AR + REF (4.8 ± 2.1 cm/s, p < 0.001). Peak rapid filling velocity/e’ (E/e’) was increased in both AR + PEF (14.4 ± 6.2 vs. 6.2 ± 1.3, p < 0.001) and AR + REF (18.8 ± 6.4, p <0.001 vs. normals). Independent correlates of global longitudinal strain (r = 0.6416, p < 0.001) included EF (p < 0.0001), E/e’ (p < 0.0001), and tricuspid regurgitation velocity (p = 0.0176). Conclusion: With chronic AR, there is impaired longitudinal function despite preserved EF. Moreover, global longitudinal strain was well correlated with noninvasive estimated LV filling pressures and pulmonary systolic arterial pressures.

Study Objective Although data from the Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Venous Thrombosis and Pulmonary Embolism (RECORD) 1-4 trials have shown a similar postoperative bleeding risk between rivaroxban and enoxaparin in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), anecdotal observations from local institutions have suggested that postoperative bleeding rates seemed higher in patients who received rivaroxaban than those reported in the RECORD trials. Thus, the objective of this pilot study was to assess postoperative bleeding events observed in clinical practice in patients receiving rivaroxaban after undergoing THA and TKA and to compare their results with those published in the RECORD trials. Design Retrospective cohort study with a comparator group of patients from the RECORD 1-4 trials. Setting Two institutions within a regional health care system. Patients Four hundred forty adults who received at least one dose of rivaroxaban 10 mg daily after undergoing THA or TKA in the two institutions between August 2011 and October 2013 (cohort group), and 6183 patients who received rivaroxaban in the RECORD 1-4 trials (comparator group). Measurements and Main Results Postoperative bleeding was assessed in the cohort patients versus the patients in the RECORD trials. The primary outcome, occurrence of any postoperative bleeding, was a composite of major and clinically relevant nonmajor bleeding as defined in the RECORD trials. Any postoperative bleeding occurred in 6.8% of the cohort patients versus 3.2% of the RECORD trial patients (p<0.0001); 1.4% of the cohort patients versus 0.38% of the RECORD trial patients suffered a major bleed (p=0.013). Within defined major bleeding, bleeding leading to reoperation and clinically overt extrasurgical site bleeding resulting in either a hemoglobin level decrease of at least 2 g/dl or transfusion of 2 units or greater of packed red blood cells were reported in 0.68% versus 0.19% (p=0.073) and 0.68% versus 0.13% (p=0.032), respectively, of the cohort patients versus the RECORD trial patients. Conclusion Overall, any postoperative bleeding in the cohort patients occurred significantly more frequently than that observed in the RECORD trial patients. The major bleeding rate was also significantly higher in the cohort patients, influenced by higher rates of bleeding leading to reoperation and clinically overt extrasurgical site bleeding resulting in either a hemoglobin decrease of at least 2 g/dl or transfusion of two units or greater of packed red blood cells. These findings from our pilot study are thought provoking and, thus, invite further investigation.

Type 2 diabetes mellitus (T2DM) carries a high prevalence in the United States and worldwide. Therefore, the number of medication classes being developed and studied has grown. The individualized management of diabetes is accomplished by evaluating a medication's efficacy, safety, and cost, along with the patient's preference and tolerance to the medication. Sodium glucose co-transporter 2 inhibitors are a new therapeutic class indicated for the treatment of diabetes and have a unique mechanism of action, independent of beta-cell function. The first agent approved by the Food and Drug Administration (FDA) was canagliflozin in March 2013. Two agents - dapagliflozin and empagliflozin - were FDA-approved in January and July 2014, respectively. A clear understanding of the new class is needed to identify its appropriate use in clinical practice. Members of the American College of Clinical Pharmacy Endocrine and Metabolism Practice and Research Network reviewed available literature regarding this therapeutic class. The article addresses the advantages, disadvantages, emerging role, and patient education for sodium glucose co-transporter 2 inhibitors. Key limitations for this article include limited access to clinical trial data not published by the pharmaceutical company and limited data on products produced outside the United States.

Heart failure (HF) affects 6 million Americans, has an expected increasing prevalence in the next 20 years, and has a 5-year mortality rate of 50%. It represents the number one reason for hospitalization in patients older than 65 years. Recent legislation has increased the accountability of care of patients with HF, specifically readmission rates for HF in less than 30 days. This increased focus on HF readmission rates has led many health care organizations to reassess transition-of-care issues (i.e., from home to hospital, from hospital to home) and possible interventions to positively impact these readmission rates. During this process, home health care providers play an integral role and should be aware of possible issues to ensure optimum care for patients.

The primary clinical characteristics of cystic fibrosis (CF) are malnutrition caused by malabsorption secondary to pancreatic insufficiency, chronic pulmonary infections, and male infertility. The major cause of morbidity and mortality are bronchiectasis and obstructive pulmonary disease. Lung disease in CF is manifested by this chronic lung disease progression, with intermittent episodes of acute worsening of symptoms called pulmonary exacerbations. Once the patient has stabilized, and if suitable care can be arranged, these interventions are often transitioned to the home. This review summarizes important points pertinent to the use of intravenous and inhaled antimicrobials that may be encountered by prescribers, nurses, technicians, and case managers in the home health setting. Appropriate dosing, indications, adverse drug reactions, monitoring parameters, and practicality of both intravenous and inhaled antimicrobials are discussed.

Diabetes mellitus, whether type 1 or type 2, offers special challenges to home health care providers. Treatment of diabetes can become increasing complex. While insulin remains the cornerstone of treatment in patients with type 1 diabetes (T1DM), the utilization of insulin to safely control blood glucose is also necessary for many patients with type 2 diabetes (T2DM). Many different insulin products are available, with each product possessing different characteristics and adverse effect potential. Balancing glycemic control with patient safety is paramount. The individualization of insulin therapy can be challenging for both patients and health care professionals. Regular evaluation of blood glucose monitoring is vital for patient assessment. This article provides a review of insulin for providers caring for patients in the home health care setting.

Home health clinicians are uniquely qualified to fully evaluate patient falls risk and carry out clinical interventions to reduce risk. The objectives of this article are to give home health providers an update on the risk factors for falling, review the current guideline recommendations for prevention of falls, and provide a stepwise approach to evaluate patients and apply the clinical literature to decrease falls in older patients living at home. Many falls may be prevented with patient screening, assessment of risk, and modification of risk factors. Since the risk of falling is an interaction between three groupings of patient-specific factors, namely, environmental factors, diseases/disorders, and medication use, a multifactorial fall risk assessment can help identify the factors to consider modifying in an individual patient.

Objective: To report a case of deep vein thrombosis (DVT) with symptomatic pulmonary embolism (PE) possibly associated with the use of coltsfoot, kava, or blue vervain. Case Summary: A 27-year-old white male presented with leg pain and swelling, tachycardia, and pleuritic chest pain. He had no significant medical history. A medication history revealed extensive herbal medication use including: coltsfoot, passionflower, red poppy flower petals, wild lettuce, blue lily flowers, wild dagga flowers, Diviners Three Burning Blend® (comprised of salvia divinorum, blue lily, and wild dagga), kavakava, St. John's Wort, blue vervain, and Dreamer's Blend® (comprised of Calea zacatechichi, vervain, Entada rheedii, wild lettuce, and Eschscholzia californica). Lower extremity Doppler ultrasound and computed topography (CT) of the chest revealed DVT and PE. A hypercoagulable work-up was negative. The patient was treated with enoxaparin and warfarin and was discharged home. Discussion: While no distinct agent can be identified as a sole cause of this venous thromboembolic event, coltsfoot could potentially affect coagulation through its effect on vascular endothelial cells as they regulate nitric oxide. Nitric oxide is a known mediator of platelet activity and coagulation, particularly in the pulmonary vasculature. Kava and vervain have estrogenic properties. Conclusions: Of the medications consumed by this self-proclaimed "herbalist," coltsfoot is a potential cause of venous thromboembolic disease (VTE).

Falls are caused by many factors in older patients. Medications have been shown to be a risk factor for falls, and studies have shown that patients taking more than five total medications may have a two-fold increased risk of impaired balance. A more recent model suggests only medications with sedating and anticholinergic properties contribute significantly to physical impairment. The authors of this paper helped to develop a multidisciplinary clinic to evaluate the risk of falls in at-risk patients. We present the case of a woman on multiple medications that increased her risk of falling. Of note, this patient was taking a total of 14 prescription medications, seven of which were considered sedating. Based on a comprehensive medication evaluation, six specific changes were recommended to improve this patient's medication regimen and reduce her risk of falling.

BACKGROUND: The Modification of Diet in Renal Disease (MDRD) formula and a modified version of the Cockcroft-Gault (CGm) formula adjusting for body surface area have been found to more accurately estimate glomerular filtration rate (GFR) compared with the original CG equation in specific patient populations. To date, the use of these formulas in determining drug dosage and estimating drug elimination has not been thoroughly investigated. OBJECTIVE: To evaluate the ability of the MDRD and CGm formulas to predict aminoglycoside elimination rate and clearance. METHODS: A 6-month prospective, noninterventional, pharmacokinetic study was conducted at a university teaching hospital. Patients receiving aminoglycoside antibiotics (amikacin, gentamicin, or tobramycin) were eligible for study inclusion. Predicted elimination rate and aminoglycoside clearance were calculated for each patient using the MDRD and CGm formulas. Actual (patient-specific) elimination rate and aminoglycoside clearance were calculated for each patient using measured aminoglycoside serum concentrations. Predictive ability of the formulas was compared through Spearman correlations and Student's t-tests. Accuracy of formula estimates was also evaluated. RESULTS: Seventy-one patients met study inclusion criteria; the majority (82%) were in an intensive care unit. The 6-variable MDRD formula was found to be a significantly better predictor of aminoglycoside clearance (p = 0.035) compared with CGm. There was no statistically significant difference between the 2 methods in predicting patient-specific elimination rates (p = 0.167). Among subgroups, the MDRD formula was a significantly better predictor of aminoglycoside clearance for patients with an estimated GFR less than 60 mL/min (p = 0.027). CONCLUSIONS: The 6-variable MDRD performs better than the CGm formula in predicting aminoglycoside clearance and may be considered as a tool in aminoglycoside dosing recommendations.