Northern Arizona VA Health Care System

Few published reports have suggested a substantial interaction between cranberry juice and warfarin, although a definite link could not be established. We encountered a patient taking stable doses of warfarin who developed major bleeding and high INR soon after starting daily cranberry juice. No other identifiable reasons for the high INR were apparent. The patient resumed his usual dose of warfarin after stopping the juice. This case suggests a definite relationship between cranberry juice and warfarin.

Aims The objective of this study was to determine the effectiveness and safety of cefazolin vs. antistaphylococcal penicillin (ASP) in the treatment of methicillin‐sensitive Staphylococcus aureus (MSSA) bacteraemia. Methods The databases of PubMed, Embase and Cochrane Central were used to identify comparative trials of cefazolin vs. ASP in MSSA bacteraemia. Meta‐analysis of included trials was performed to assess any differences regarding mortality, clinical cure, recurrence and withdrawal from adverse effects between groups. Data were analysed using fixed effect model. Studies were weighted using Mantel–Haenszel methodology. Heterogeneity was calculated using the I 2 statistic. Results Nine retrospective and one prospective trials were identified involving 4728 patients, 2954 with ASP and 1774 with cefazolin. Meta‐analysis showed a lower mortality rate with cefazolin vs. ASP using fixed effect model [risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69–0.88, P < 0.0001] with borderline high heterogeneity (I 2 = 51%). Clinical cure was noted more often with cefazolin (RR 1.09, 95% CI 1.02–1.17, P = 0.02), although no difference was noted with relapse (RR 1.29, 95% CI 0.96–1.74 P = 0.09). Analysis also showed more withdrawals from adverse events with ASP vs. cefazolin (RR 0.27, 95% CI 0.16–0.47, P < 0.00001). A minority of patients enrolled in these trials were admitted to the intensive care unit or had endocarditis (11.4% with ASP and 9% with cefazolin). Conclusion Our meta‐analysis of retrospective data demonstrate that cefazolin is more effective and safer ASP in patients with MSSA bacteraemia from various causes. Low quality of trials, borderline high heterogeneity, and possible publication bias may limit the validity of our findings. Randomized trials are needed to confirm these findings.

BACKGROUND: The Patient Self Determination Act of 1990 mandates healthcare providers (HCP) to speak with patients about end-of-life preferences and advance directives (AD). HCP work with patients of varying cultures, and standard ADs do not address cultural differences. In order to understand various cultural beliefs, cultural sensitivity is important especially when discussing advance care planning (ACP). AIMS: Individuals from differing ethnic backgrounds are likely to turn to their traditional norms of practice when ill or treatment choices must be made. An AD that addresses varying cultural values and beliefs was sought. METHODS: A comprehensive review of the literature was conducted. Articles selected for review included qualitative and quantitative studies. The evidence was evaluated and synthesized for information related to cultural sensitivity and ADs. FINDINGS: Three common themes emerged related to ACP discussions and culture. Healthcare provider awareness, communication, and education concerning cultural differences and ACP assisted in meeting the needs for end-of-life planning in the current era of increased globalization. Education for HCP on cultural differences and how to lead discussions promoted ACP. IMPLICATION FOR PRACTICE: ADs are an essential part of health care and promote patient-centered care. (HCP) should be able to recognize differing cultural values and beliefs in order to initiate conversations about end of life. Initiating conversations about ACP can be facilitated by using open-ended questions that respect the values and beliefs of various cultures.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Case reports suggest an association between cranberry juice and potentiation of warfarin. Studies using 240 ml of cranberry juice daily demonstrated no interaction. It is unknown if higher amounts of cranberry juice will interact with warfarin. WHAT THIS STUDY ADDS: Cranberry juice at 240 ml twice daily does not alter the pharmacodynamics of warfarin. AIM: To determine if high-dose cranberry juice (240 ml twice daily) alters the pharmacodynamic action of warfarin. METHODS: Ten male patients taking stable doses of warfarin were given cranberry juice at 240 ml twice daily for 7 days. Prothrombin times were drawn at baseline and days 2, 6 and 8 after administration of the juice. Prothrombin times were averaged for each day and mean times were compared from each study day to baseline using repeated measures ANOVA. RESULTS: There was no statistical difference between mean prothrombin time at baseline and any day tested during juice administration. CONCLUSIONS: Cranberry juice (240 ml twice daily for 1 week) did not alter the pharmacodynamics of warfarin in patients.

BACKGROUND: Observational studies have suggested an increased risk of nephrotoxicity when piperacillin-tazobactam is added to vancomycin, although the data are confliciting. OBJECTIVE: To perform a meta-analysis of identified studies to assess if adding piperacillin-tazobactam to vancomycin increases the incidence of nephrotoxicity. METHOD: A systematic review of PubMed, EMBASE, Cochrane Central, and Google Scholar was conducted to identify studies. Studies selected for meta-analysis were full length reports, retrospective or prospective, and designed specifically to assess if the combining piperacillin-tazobactam with vancomycin increases nephrotoxicity. RESULTS: Six observational trials involving 963 patients were identified and analyzed. Five trials were retrospective and one was prospective. Vancomycin/piperacillin-tazobactam was compared to vancomycin alone in 2 trials, to vancomycin/cefepime in 3 trials, and vancomycin/cefepime or meropenem in one. Meta-analysis showed a statistical increase in the incidence of nephrotoxicity when piperacillin-tazobactam/vancomycin is compared to the control group (2.26 95% CI 1.41-3.63, p= 0.0007). No differences were noted between groups in patients requiring renal replacement. CONCLUSION: Adding piperacillin-tazobactam to vancomycin increases the risk of nephrotoxicity when compared to vancomycin alone or vancomycin with either cefepime or meropenem.

BACKGROUND: Rehabilitation outcomes for patients with total knee arthroplasty (TKA) after hospital discharge are not well understood. PURPOSE: The purpose of this retrospective cohort study was to describe outpatient physical therapy (PT) after TKA and compare short-term (2 months) functional and clinical outcomes of patients following TKA who were discharged from the hospital to home and received (a) outpatient PT immediately (OP) or (b) home health PT before outpatient PT (HH). METHODS: The medical records of 109 men and women postoperative TKA discharged home were abstracted for the 6-minute walk test (6MWT), Knee Osteoarthritis and Outcome Score (KOOS), and knee range of motion (ROM) preoperatively and after discharge from all postoperative PT. Patients received outpatient clinic-based PT immediately after discharge from the hospital (OP) (n = 87) or home health PT before continued rehabilitation in an outpatient setting (HH) (n = 22). RESULTS: Despite demographic differences between OP and HH preoperatively, adjusted models revealed no significant differences among KOOS, 6MWT, or knee ROM between OP and HH upon completion of postoperative PT. Patients in OP completed PT on average 20 days sooner (p = .0007), although the amount of time in outpatient PT (p = .55) and the number of outpatient PT visits (p = .68) were similar between groups. CONCLUSION: Gains in function were achieved by patients in OP and HH independent of the postoperative PT setting, although OP achieved gains sooner.

McGhee, Timothy L. MSN, RN; Weaver, Paul RN; Solo, Stacie BSN, RN; Hobbs, Melissa MSN, RN Author Information

In Brief Emphasizing required skills, knowledge, and education, this article describes the role of clinical nurse educators (CNEs) and the best practices CNEs can use to optimize education for nurses.

Purple toe syndrome is a rarely reported adverse effect of warfarin. In all described cases, the syndrome occurred relatively quickly after initiation of warfarin with little recommendation for treatment in patients needing continued anticoagulation. We encountered a patient who developed purple toes after 1 year of warfarin therapy. The warfarin was stopped, and fondaparinux was substituted with prompt resolution of all his symptoms. This is the first case describing late onset purple toe syndrome with warfarin with successful substitution with fondaparinux.

BACKGROUND: Studies of alcohol withdrawal syndrome indicate a higher prevalence in men than in women. However, it is unknown how the condition differs between the sexes. OBJECTIVE: To assess alcohol withdrawal syndrome in women versus men at a single site. METHODS: All cases of alcohol withdrawal syndrome at a public hospital from 2010 to 2014 were reviewed retrospectively. For all 1496 episodes, age, sex, and admission to a general care unit (ward) versus the medical intensive care unit were ascertained, along with patient survival. A detailed analysis was performed of 437 cases: all 239 patients admitted to the medical intensive care unit, all 99 female patients admitted to the ward, and 99 randomly selected male patients admitted to the ward. Also analyzed were administration of benzodiazepines, disease course, length of stay, and complications. RESULTS: Men accounted for 92% of all cases (1378 of 1496; P < .001) and medical intensive care unit admissions (220 of 239; P < .05). Sixteen percent of both men and women were admitted to the medical intensive care unit. Men were older (mean age, 45.6 vs 43.9 years; P < .01), and women required more benzodiazepines. Similar rates of complications occurred in both sexes, although women had a higher rate of pancreatitis and men had higher rates of pneumonia, higher rates of sepsis, and longer stays. CONCLUSIONS: Men and women with alcohol withdrawal syndrome have similar complications, courses, and intensive care unit admission rates, although men are more prone to pneumonia and have longer stays.

What is known and Objective: One case report demonstrated warfarin resistance associated with sulphasalazine therapy. Our objective is to report on a case of warfarin potentiation rather than resistance, associated with sulphasalazine therapy. Case summary: The patient was taking warfarin for two mechanical heart valves and was prescribed sulphasalazine for inflammatory bowel disease. He had stable international normalized ratios (INRs) before sulphasalazine administration. Approximately 3 weeks after starting sulphasalazine, he presented to the anticoagulation clinic with bruising and an INR of 6·1. The sulphasalazine was stopped, and the warfarin was held for 3 days; then the previous dose was resumed. Three weeks later, the INR returned to a therapeutic level. What is new and Conclusion: This is the first case of sulphasalazine potentiating the effect of warfarin. Sulphasalazine may potentiate the hypoprothombinemic effect of warfarin.

It is a certainty that some patients taking warfarin will be prescribed new direct-acting antiviral agents (DAAs) for hepatitis C, given the increasing use of these medications. This raises the possibility of a drug interaction with warfarin, which heretofore has been rarely described, especially with the new agent sofosbuvir–velpatasvir. This product is highly effective for all genotypes of hepatitis C and is an attractive alternative to other DAAs, especially for more resistant strains. To date, there are no citations on PubMed or in the company literature describing a warfarin interaction with this product, although reports of warfarin antagonism are emerging with other DAAs.1–3 We describe an apparent interaction between warfarin and sofosbuvir–velpatasvir that resulted in a subtarget International Normalized Ratio (INR) and subsequent thrombosis and hospitalization. A 63-year-old man appeared in our emergency department (ED) with leg pain and a cold foot. He had a history of femoral-popliteal bypass surgery and was receiving warfarin to prevent graft thrombosis. His target INR was 2.5–3.5, and he was followed in the facility’s anticoagulation clinic. Fourteen days before arriving at the ED, he had begun treatment for hepatitis C genotype 3a infection with a fixed combination of sofosbuvir 400 mg and velpatasvir 100 mg (1 tablet daily). For the 6 weeks before that, his INR had generally been within the target range while he received a stable total weekly warfarin sodium dose of 102.5 mg (see figure).

Non-invasive prenatal screening (NIPS) using cell-free DNA is a screening test for fetal aneuploidy offered by a variety of prenatal healthcare providers. Guidelines for genetic screening consistently recommend that providers facilitate informed choices, which have been associated with better psychological and clinical outcomes than uninformed choices. The multidimensional measure of informed choice (MMIC) is a widely used and theory-based measure that combines knowledge, values, and behavior to classify decisions as either informed or uniformed. We implemented a previously validated version of the MMIC for women offered NIPS to describe the choices made by women receiving prenatal care at the Vanderbilt University Medical Center. The survey included the Ottawa Decisional Conflict scale, an outcome measure used for validation of choice categorization. We found that most women (87%) made an informed choice about NIPS. Of the women categorized as uninformed, 67% had insufficient knowledge, and 33% had an attitude discordant with their decision. The vast majority of respondents (92.5%) underwent NIPS and had a positive attitude toward screening (94.3%). Ethnicity (p = 0.04) and education (p = 0.01) were found to be significantly associated with informed choice. Decisional conflict was extremely low among all participants, with only 5.6% of all participants demonstrating any form of decisional conflict, and all being categorized as having made an informed choice. This study suggests that pre-test counseling by a genetic counselor results in high rates of informed choice and low-decisional conflict amongst women offered NIPS by genetic counselors, though more research is required to determine if rates of informed choice remain high when NIPS is offered by other prenatal providers.

INTRODUCTION: Military Veterans have an increased risk of suicide compared to the general population, but less is known about changes in risk with the onset of the COVID-19 pandemic, or whether any changes have been moderated by psychiatric or demographic factors. The primary objective was to test the hypothesis that the likelihood of suicide attempt or death by suicide was stable during the first year of the pandemic versus the preceding year for the full sample. A second objective was to test the hypothesis that, in contrast, risk increased for Veteran subgroups characterized by traditional risk factors (e.g., psychiatric diagnosis). MATERIALS AND METHODS: We extracted electronic health record data for 771,570 Veterans who received one or more health care visits between March 13, 2019, and March 12, 2021, at eight VA hospitals across the southwestern United States. Primary outcome measures were suicide attempts and deaths by suicide. Predictor variables included psychiatric diagnoses and demographic factors. RESULTS: Multivariable models indicated that the odds of death by suicide did not change during the first year of the COVID-19 pandemic, while the odds of making a suicide attempt declined. Veterans treated for major depression were at heightened risk for attempting suicide in both years, but the association was smaller during the pandemic than the year prior. In contrast, the relative risk of attempt for Veterans who were never married and Veterans treated for a non-alcohol, non-opioid substance-use disorder increased during the pandemic. CONCLUSIONS AND RELEVANCE: The findings suggest that the pandemic has not led to an increase in suicidal behavior, which is consistent with other studies, although the degree of decline varied across diagnostic and demographic groups. Further longitudinal research is needed to evaluate whether the prolonged nature of COVID-19 may lead to changes in risk over time.

WHAT IS KNOWN AND OBJECTIVE: It is unknown how letter communication vs. telephone communication compares in terms of affecting outcomes in patients followed in a busy anticoagulation clinic. This study was performed to determine if sending letters to communicate laboratory results and future appointments with patients enrolled in a pharmacy managed anticoagulation clinic is an effective alternative to telephone communication. METHODS: A retrospective review of quality assurance data currently collected at our facility was performed. Data were analyzed 4 months before and 4 months after the implementation of the letter notification. Data on percent international normalized ratio (INR) in therapeutic range, missed laboratory draw frequency and major bleeding events were collected daily, compiled monthly and then compared between the telephone and letter groups. RESULTS: There was no statistical difference in the percentage of INRs that were within goal range before and after letter initiation. There was a slight increase in the percentage of INR laboratory draws that were missed after the implementation of the letters (23% vs. 26%, P = 0·002). There were more major bleeding events after letter initiation, but this did not reach statistical significance. Approximately 80% of the patients received letters as the method of communication in the letter group. WHAT IS NEW AND CONCLUSION: The use of letters to notify warfarin patients with laboratory results is an effective method of communication without adversely affecting patient outcomes.

Enhancing staff support with debriefing programs.

Tena, Rose ADN, RN, CNOR, CPN; League, Susan AAS, RN; Brennan, Jean MSN Author Information

INTRODUCTION: Cannabis use is significantly increasing worldwide yet its cardiovascular effects and arrhythmogenic potential remain unclear. As legalization expands, it is critical to understand public health risks and clinical implications. This study evaluates the relationship between cannabis use and the risk of arrhythmias using a large, real-world dataset. METHODS: This retrospective cohort study utilized deidentified electronic health records from 68 U.S. healthcare organizations within the TriNetX network. A total of 210 817 adult cannabis users were identified and matched 1:1 with 210 817 ibuprofen users using propensity score matching across 17 baseline variables, including demographics, cardiovascular risk factors, and medication use. The primary outcomes were incident diagnoses of atrial fibrillation/flutter (AF/AFL), paroxysmal tachycardia, premature beats, and ventricular tachycardia/fibrillation (VT/VF). Outcomes were assessed using Cox proportional hazards models and Kaplan-Meier survival analyses. RESULTS: Cannabis use was significantly associated with an increased risk of multiple arrhythmias compared to ibuprofen use. The incidence of AF/AFL was 1895 versus 1332 cases (HR = 1.549, 95% CI: 1.444-1.662, p < 0.001). Paroxysmal tachycardia occurred in 1065 versus 672 patients (HR = 1.791, 95% CI: 1.626-1.973, p < 0.001), and premature beats in 1135 versus 745 patients (HR = 1.739, 95% CI: 1.585-1.908, p < 0.001). The most pronounced relative risk was observed for VT/VF, with 97 versus 35 cases (HR = 3.078, 95% CI: 2.089-4.533, p < 0.001). All associations remained statistically significant after adjustment, and Kaplan-Meier curves demonstrated lower arrhythmia-free survival in cannabis users across all endpoints. CONCLUSION: Cannabis use was associated with an increased risk of multiple arrhythmias, particularly atrial fibrillation and ventricular arrhythmias. These findings highlight the need for further research on the cardiovascular effects of cannabis and reinforce the importance of patient counseling regarding its potential arrhythmogenic risks.

Type 2 diabetes is a global epidemic. Increasing evidence shows that estrogen has protective effects on insulin sensitivity. Decreased estrogen levels affect adipocytes response to insulin leading to increased circulating glucose levels and insulin resistance. AMP‐activated protein kinase (AMPK) regulates cellular energy balance due to its role in glucose, lipid, and protein metabolism. Activation of AMPK results in translocation of glucose transporter 4 (GLUT4) to the plasma membrane which mobilizes glucose into the cell. The seed extract of Nigella sativa (NS) reduces elevated glucose levels. However, the molecular mechanisms involved in regulating glucose transport by NS remain elusive. We used an estrogen deficient animal model to examine whether NS and its active ingredient thymoquinone (TQ) modulate proteins involved in regulating glucose transport: AMPK, Akt, phosphorylated AMPK and Akt, and GLUT4.Sprague Dawley rats were either sham‐operated or ovariectomized and divided into control, NS and TQ fed groups. Rats were fed the respective diets for 4 months and sacrificed. The peritoneal adipose tissue was collected and proteins were analyzed. NS fed sham‐operated rats showed significant increase in AMPK phosphorylation, compared to control sham‐operated rats. Similarly, ovariectomized rats fed TQ showed an increase in AMPK phosphorylation, compared to TQ sham‐operated rats. Moreover, rats fed NS or TQ showed an increase in GLUT4 protein content, compared to the respective control groups. However, NS and TQ did not activate Akt phosphorylation.

&lt;p&gt;El estudio del miedo ofrece una perspectiva muy sugerente para el abordaje de la Historia de las mentalidades. Pese a que, como objeto de estudio, el miedo ha incrementado su presencia en trabajos recientes, los investigadores se han centrado en ámbitos sustancialmente diferentes al aquí tratado. El agua, fuente de energía, vía de comunicación y recurso imprescindible para toda vida, ha sido vista también con suspicacia y su contacto con ella afrontado con especial prevención, de manera absoluta cuando hablamos del mar y de los lógicos peligros que entraña. Hemos recurrido a algunas de las obras literarias castellanas más conocidas del ocaso de la Edad Media para tratar de entender qué recelos e inseguridades generaba el agua a sus contemporáneos.&lt;/p&gt;