Diuretic therapy and ventricular arrhythmias in persons 65 years of age and older.

Comparatively high doses of thiazide diuretics have been implicated as a possible cause of ventricular arrhythmias. With the advent of lower recommended dosages, the effect of hydrochlorothiazide 50 mg daily alone and in combination with the potassium-sparing drug, amiloride 5 mg, on the frequency and severity of ventricular arrhythmias was examined in 37 elderly patients. The mean age was 81 +/- 2 years. The study used a randomized, double-blind, crossover design with 3 treatment phases: hydrochlorothiazide, hydrochlorothiazide + amiloride and placebo. A 24-hour Holter monitor recording and serum potassium measurement were obtained at the end of each treatment. Mean serum potassium was significantly (p less than 0.001) reduced with hydrochlorothiazide (3.5 +/- 1 mEq/liter) compared with placebo (4.1 +/- 0.1) and hydrochlorothiazide + amiloride (4.1 +/- 0.1). Serious ventricular arrhythmias occurred in 13 of 37 patients receiving hydrochlorothiazide compared with 15 of 37 receiving placebo and 9 of 37 receiving hydrochlorothiazide + amiloride. Patients who exhibited ventricular ectopy during the placebo phase tended to have an increase in the number of ventricular premature complexes receiving hydrochlorothiazide, although the difference was not statistically significant. There was a significant (p = 0.045) difference in the hourly ventricular premature complex frequency for hydrochlorothiazide compared with hydrochlorothiazide + amiloride. Patients with hypokalemia did not exhibit greater ventricular ectopic activity than those with a normal serum potassium, and concurrent digoxin therapy did not affect arrhythmia occurrence. Hydrochlorothiazide, 50 mg daily, did not affect the frequency or severity of ventricular ectopic activity in this elderly population.     

Autologous bone marrow transplantation in high-risk remission T-lineage acute lymphoblastic leukemia using immunotoxins plus 4-hydroperoxycyclophosphamide for marrow purging

Fourteen patients with high-risk T-lineage acute lymphoblastic leukemia (ALL) in complete remission underwent autologous bone marrow transplantation (BMT) in an attempt to eradicate their residual disease burden. A combined immunochemotherapy protocol using a cocktail of two immunotoxins directed against CD5/Tp67 and CD7/Tp41 T-lineage differentiation antigens in combination with the in vitro active cyclophosphamide congener 4-hydroperoxy-cyclophosphamide (4-HC) was used to purge autografts. Despite high dose pretransplant radiochemotherapy and effective purging of autografts, 9 of 14 patients relapsed at a median of 2.5 months (range, 1.2 to 16.8 months) post BMT. Two patients remain alive and disease free at 26 and 28 months post BMT. We used a novel quantitative minimal residual disease (MRD) detection assay, which combines fluorescence activated multiparameter flow cytometry and cell sorting with leukemic progenitor cell (LPC) assays, to analyze remission bone marrow (BM) samples from T-lineage ALL patients for the presence of residual LPCs. Notably, high numbers of residual LPC detected in remission BM before BMT constituted a poor prognostic indicator, providing the first evidence for the biologic significance and clinical value of in vitro T-lineage ALL LPC assays. The median value for the residual leukemia burden before BMT, was approximately 8.6 x 10(3) LPC/10(8) mononuclear cells (MNC) (approximately 0.0086% LPC). Patients with a residual leukemia burden less than this median value appeared to have a better outlook for remaining free of relapse after autologous BMT than patients with a greater leukemia burden (53 +/- 25% v 14 +/- 13%, P = .006, Mantel-Cox). By comparison, the log kill efficacy of purging, the remaining numbers of LPC in purged autografts, or the estimated numbers of reinfused LPC, did not correlate with the probability of disease-free survival (DFS). These results indicate that the primary reason for the recurrence of leukemia was inefficient pretransplant radiochemotherapy rather than inefficient purging of autografts.     

Impact of a Regional Pharmacy Call Center on Telephone Access Metrics Within the Veterans Health Administration

Purpose:

To establish a cost-effective centralized pharmacy call center to serve the patients of Veterans Integrated Service Network (VISN) 11 that would meet established performance metrics.

Methods:

A pilot project began in August 2011 with the Indianapolis VA Medical Center (VAMC) and the Health Resource Center (HRC) in Topeka, Kansas. The Indianapolis VAMC used a first-call resolution business model consisting of pharmacy technicians receiving tier 1 phone calls that could be escalated to a tier 2 line that consisted of lead technicians and pharmacists, while the HRC utilized general telephone agents that would transfer unresolved calls to the primary facility. Pre- and post-VISN 11 Pharmacy Call Center performance metrics were compared for each of the 7 facilities in the network with the goals being monthly average abandoned call rate less than 5% and average speed to answer less than 30 seconds. Cost per call was also compared.

Results:

The average abandoned call rate for the network during the year prior to VISN 11 Pharmacy Call Center implementation (August 2010-July 2011) was 15.66% and decreased to 3% in July 2014. The average abandoned call rate decreased for each individual facility. In fiscal year 2014, the VISN 11 Pharmacy Call Center was operating at a cost of $4.35 per call while providing more services than the HRC, resulting in less workload being transferred back to the individual facilities.

Conclusion:

A centralized VISN pharmacy call center is a reasonable alternative to individual facility call centers or the HRC.     

Motivations and Barriers to Routine HIV Testing Among Men Who Have Sex with Men in New York City

AIDS and Behavior - In-depth qualitative interviews explored the experiences and understandings of men 18–39 years old who have sex with men that could facilitate or prevent HIV...     

Prognostic value of exercise tests in male veterans with chronic coronary artery disease

PURPOSE: The authors evaluate the prognostic value of treadmill testing in a large consecutive series of patients with chronic coronary artery disease. Exercise testing is widely performed, but analyses of the prognostic value of test results have largely concentrated on patients referred for the diagnosis of coronary artery disease, patients after an acute coronary event or procedure, or patients with congestive heart failure. METHODS: All patients referred for evaluation at two university-affiliated Veterans Affairs Medical Centers who underwent exercise treadmill tests for clinical indications between 1987 and 2000 were determined to be dead or alive using the Social Security Death Index after a mean 5.8-year follow-up. Patients without established heart disease and those with congestive heart failure were excluded, leaving the target population of those with a history myocardial infarction or coronary intervention. Clinical and exercise test variables were collected prospectively according to standard definitions; testing and data management were performed in a standardized fashion using a computer-assisted protocol. All-cause mortality was used as the endpoint for follow-up. Standard survival analysis was performed including Kaplan Meier curves and the Cox Hazard Model. RESULTS: Of the 1,473 patients with coronary artery disease who had exercise testing, 273 (19%) patients had a revascularization procedure (Revascularization group); 813 (55%) had a history of myocardial infarction, diagnostic Q waves (MI group), or both; and 387 (26%) had a history of myocardial infarction or Q wave and revascularization (Combined group). Mean age of the patients was 61.8 +/- 9 years. A total of 401 deaths occurred during a mean follow-up of 5.8 years with an annual mortality rate of 4.5%. Only two variables, age and maximal exercise capacity, were independently and statistically associated with time to death in all three groups and were the strongest predictors of all cause mortality. CONCLUSION: A simple score based on METs, age, and history of myocardial infarction or diagnostic Q waves can stratify prognosis in patients with chronic coronary artery disease. The score enabled the identification of a group at low risk (32% of the cohort) with an annual mortality rate of 2%, a group at intermediate risk (42% of the cohort) with an annual mortality rate of about 4%, and a group at high risk (26% of the cohort) with an average annual mortality rate of approximately 7%.     

Left lower lobe ventilation is reduced in patients with cardiomegaly in the supine but not the prone position

To determine the effect of the heart on regional ventilation, Krypton-81m (81mKr) tomographic (SPECT) ventilation scans were recorded in seven patients with cardiomegaly and four normal subjects in the supine and prone positions. All patients had a cardiothoracic ratio of greater than 0.50 and clear lung fields radiographically. Using standard gamma camera tomographic reconstruction techniques, images of transaxial slices were obtained during a 360 degree rotation around the thorax of the subject breathing the radioactive gas 81mKr. The transaxial images, acquired over 10 min were aligned in each posture at the level of the cardiac apex, mid-heart, and aortic arch and were matched in relation to a radioactive marker on the chest wall and to anatomic landmarks. A horizontal line (gravity independent and parallel to the couch) was drawn on the transaxial section through the dorsal regions of the right and left lung. Counts per resolution element (12 to 15 mm) were plotted along this line and the ratios of the peak values in right and left lung compared. These ratios represent differences in regional ventilation per unit lung volume. In controls the mean left-to-right (L/R) peak count ratio varied from 0.91 to 1.00 at the three levels (range: 0.76 to 1.04); there were no significant differences between supine and prone. In patients with cardiomegaly the mean (+/- SEM) L/R peak count ratio at cardiac apex, mid-heart, and aortic arch was 0.46 (+/- 0.08), 0.55 (+/- 0.07), and 0.89 (+/- 0.08) when supine and 1.04 (+/- 0.07), 1.05 (+/- 0.05), and 1.08 (+/- 0.07) when prone, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coffee and coronary heart disease.

OBJECTIVE--We determined if coffee consumption is associated with an increased risk of developing coronary heart disease. DATA IDENTIFICATION--Articles published between 1966 and August 1991 examining a possible link between coffee and coronary heart disease were identified by a computer-aided literature search (Medline) and by standard bibliographic searches. STUDY SELECTION--All prospective cohort studies providing data on daily coffee consumption and coronary events (acute myocardial infarction and/or coronary death) were included. DATA EXTRACTION--Data from each published article were extracted. Additional unpublished data augmenting those published for one study were also included. Each cohort was categorized by reported daily coffee consumption. Incidence of coronary events at each level of coffee consumption was the primary outcome. RESULTS--Eleven prospective studies were included. The coronary events for subjects consuming little or no coffee (less than or equal to 1 cup per day) were compared with event rates for those consuming greater amounts of coffee. The studies exhibited heterogeneity of results. The typical odds ratios and 95% confidence intervals across studies were estimated by logistic regression analysis. Coffee intake from 1 to 4 cups per day was not associated with any increase in coronary heart disease occurrence compared with 1 cup or less per day (odds ratio, 1.01; confidence interval [0.93, 1.11]). The odds ratios for 4 to 6 and 6 cups or more per day compared with up to 1 cup per day were 1.01 (0.90, 1.12) and 1.09 (0.97, 1.22), respectively. CONCLUSIONS--There is no association between coffee consumption and the occurrence of coronary heart disease. This conclusion holds in the absence of adjustment for other coronary risk factors.