Aims: Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation. Methods and results: We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-toevent multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24). Conclusion: In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.
Background Automated Dispensing Cabinets (ADC) offer several benefits to the organisation and the user. They provide nurses with near total access of medications, ensure greater control of medications and reduce medication errors. It was necessary to evaluate in which way the ADC could potentially reduce the drug consumption on the ward. Purpose To estimate the return on investment (ROI) of an ADC taking into accounts only the reduction in drug consumption. Materials and methods The drug consumption in two wards of similar characteristics of internal medicine was compared in a tertiary hospital. The ward used as a control did not have an ADC and distribution of medicines was made from ward stock. The test ward made use of an ADC model OmniSupplier. An inventory of the medicines in both wards was made on January 10th, 2010. During a one year period 323 drugs were monitored in both wards, and the drug consumption data analysed and compared. Results Two wards were selected with 29 patients each. The drug consumption during the one year period in the control ward came to 87.210 Euros, whereas the total cost of the test ward was 73.001 Euros. This represents a difference of 13.719 Euros (16,3% reduction) in drug consumption. The value of the stock in the control ward was 7.802 Euros, while the value of the test ward was 3.392 Euros, with a median stock reduction of 56,5%±21. Overall, when comparing the results obtained from the two wards, a consistent reduction is observed in almost all medicines. In some medications and dosage forms, the reduction of consumption was more significant for example oral analgesics, oral penicillins, simvastatin, antacids/gastric protectors and oral mucolitic drugs. At our hospital, the cost of the ADC, as configured, was approximately 55.000 Euros (costs of ADC's are dependent upon the number of drawers and hardware configuration and start at approximately 25.000 Euros) plus a maintenance contract of around of 3.000 Euros per year. Taking into account only the reduction in drug consumption, if The authors consider a 5 year maintenance contract, the cost of the ADC would be 70.000 Euros. If The authors divide this by the 13.719 Euros of the reduction in drug consumption, then an ADC could be payed off in about 5 years. Conclusions The investment for the installation of the ADC can be justified on the reduction in drug consumption on the war.
BackgroundThe engagement of FcGRs by TNF antagonists could affect macrophage mediated clearance of immune complexes.PurposeThe aim of our study was to explore the potential role of FcGR2A genetic polymorphism as a predictor of tocilizumab efficacy in rheumatoid arthritis (RA) patients.Material and methodsThe FcGR2A (A >G) (rs1801274) genetic variant was genotyped using predesigned TaqMan genotyping assay technology and analysed on a ViiA7 real time PCR system. Clinical response was evaluated at 24 weeks with the use of the 28 joint disease activity score criteria (DAS28). The endpoint was a change in DAS28 (cDAS28). Statistical analysis was performed using SPSS v.20ResultsClinical data for 140 tocilizumab treated patients were obtained. The patients were aged (mean±SD) 53.25 ± 12.42 years; 79% were female. Mean DAS28 at baseline was 5.71 ± 1.13. The FcGR2A-AA polymorphism was significantly associated with cDAS28 (AA vs no AA p = 0.01, OR=0.14, 95% CI 0.02 to 0.81; AG vs no AG p = 0.007, OR=9.52, 95% CI 1.80–14.70).ConclusionOur results confirm that FcGR2A (A >G) rs1801274 polymorphisms could be useful as a genetic marker of tocilizumab efficacy in RA patients. More studies are necessary to confirm these results.No conflict of interest.
Background One of the activities of the pharmacist in a hospital is the screening of the electronic treatments for inpatients. During this process, some errors can be found in prescriptions. Pharmacist interventions are important to minimise the risk to the patient and increase the quality of care. Purpose To analyse pharmacist interventions in electronic prescribing and degree of acceptance by doctors. Materials and methods We analysed the pharmacist interventions during the period June 2011 – May 2013. After the first year a presentation about the results of the analysis was given to the pharmacy team, highlighting the most relevant and original interventions and proposals for better communication with the physician. Interventions are made through the computer during the validation (Lantools program). Results The total number of interventions made was 2139 (788 first year and 1351 second year) with an average of 2.9 per day. The most common reasons were: dose adjustment for renal failure (26%), switching from intravenous to oral route (16%) and wrong dose (13%). The most frequent drugs were enoxaparin (18%), pantoprazole (12%) amoxicillin/clavulanic acid (6%) and paracetamol (5%). Of the recommendations that were reviewed (69%), 58% were accepted by the doctor. Conclusions We observed that several interventions were not recorded. After the presentation the number of pharmaceutical interventions increased considerably; it seems to be a good motivational strategy for pharmacists. There are many reasons and drugs, but adjustment for renal failure (especially enoxaparin) and switching to oral route (especially pantoprazole) are the ones made more frequently. Communication with physicians must be improved in order to increase the degree of acceptance. No conflict of interest.
Conclusion This study systematically and rigorously identified a set of 31 items which are important for assessing pharmaceutical complexity. This information can then be used for the development and refinement of future and current pharmaceutical complexity screening tools that can aid more efficient targeting of hospital clinical pharmacy services.
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