Alternative strategies to achieve cardiovascular mortality goals in china and india

High blood pressure is a leading modifiable risk factor cardiovascular disease (CVD) mortality which is why controlling this has become such a big focus for so many healthcare providers. The US currently uses a treat-to-target strategy. Europe on the other hand uses a benefit-based, tailored treatment strategy in which therapy is initiated for patients with high estimated CVD risk. Both of these emphasize that the goal of controlling blood pressure is not to lower it but to avoid CVD events. The team in this study used models to simulate adults ages 30 to 70 in divers populations. The study had three groups, the US method, the European method, and a hybrid of the two.

It turns out that the study showed that the treat-to-target would be the best model to use in both China and India to allow for the most decrease in risk for CVD related events. Less people would be treated under the other system although treatment strategies would be similar.


Basu S, Yudkin JS, Sussman JB, Millett C, and Hayward RA. Alternative strategies to achieve cardiovascular mortality goals in china and india. Circulation. 2016;133:840-48.

Psychopathological aspects of kidney transplantation: Efficacy of a multidisciplinary team

End stage renal disease is a common disability that requires kidney transplantation. The ability of a healthcare team to complete this transplantation can return patients to a much more satisfactory quality of life. Although, treatment and care after transplantation can be very complex. Administration of immunosuppressive drugs is very important following transplantation and the slightest deviation from the proper dosing regimen can increase the chances of rejection. The article states that there is a growing need for proper communication between the interdisciplinary team, which would include pharmacists, especially solid organ transplant specialists. This communication is essential to reduce the risk of rejection. As future pharmacists we need to be at the forefront to help create guidelines and protocols for such procedures. We need to establish ourselves as a crucial member of the healthcare team, proving positive outcomes for the patients and hospital units we serve. Adherence following treatment is also a huge issue for patients that have unsuccessful transplants. As the pharmacist how can we best address this issue using our motivational interviewing techniques?

De Pasquale C, Veroux M, Indelicato L, et al. Psychopathological aspects of kidney transplantation: Efficacy of a multidisciplinary team. World J Transplant. 2014;4(4):267-75.






A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics

Stroke care is an emergency situation that can be challenging to deal with. Providing a patient with IV thrombolysis for a misdiagnosed stroke or stroke mimic can cause actual thrombolysis. This of course will increase the risks of adverse events following drug administration. The study here looked at the population of stroke patients versus the population of stroke mimic patients. In terms of patient population it was determined that there is a distinct difference between the two. The stroke mimic cohort had a younger mean age of 59.9 years while the stroke cohort mean age was 73.7 years. All clinical diagnoses of the cohorts were confirmed by expert consensus after imaging review and various other factors. The study concluded that even though there are striking similarities in clinical presentation of the two events the stroke mimic cohort consists of a different population. This cohort was also associated with fewer adverse effects.

This article goes to show that staying up to date on the current literature is essential for healthcare providers. While there is increasing education and information available regarding stroke it is important to avoid misdiagnosing a patient. Physiological factors and other patient history information should always be taken into consideration when making the decision to give a patient a certain drug based on diagnosis. It’s important to consider all options while still providing care in a timely manner. Other than completing this assignment for class that allows us to look at the most recent literature, what are some other strategies to staying relevant in the field?

Prasanthi S, Dipender G, Gheed M, et al. A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics. J Stroke Cerebrovasc Dis. 2015.

Long-term outcome of patients with chronic thromboembolic pulmonary hypertension

A rare complication of acute pulmonary embolism is chronic thromboembolic pulmonary hypertension which is characterized by fibrothrombotic obstructions of large pulmonary arteries in conjunction with small-vessel arteriopathy. The usual treatment for this is a surgery, pulmonary endarterectomy, but in patients who cannot be operated on, they can be treated with medicine. This study compares the effects and outcomes between two groups, one including pateints who receive an operation for their chronic thromboembolic pulmonary hypertension while the other group was only treated medicinally. This is the first study to take a prospective, large-scale, international registry of newly diagnosed patients with CTEPH and include patients who are operated on and those who are not. The most significant thing about it is how that it was long-term.

It turned out that sixty percent of patients were operated on and forty percent were not operated on either by their own decision or for medical reasons. In total, 143 patients died, 51 of which were operated on and 92 that were not operated on. The significant find was the fact that patients that were operated on had a significantly better long-term survival than not-operated patients. Patients were eight years younger, had higher six minutes walking distance and higher cardiac index for those who were operated on. Survival for not-operated patients at 3 years was on seventy percent compared to eighty-nine percent for those who were operated on. One of the biggest determinants of survival was actually the presence of comorbidities such as cancer, coronary disease, left heart failure, and chronic obstructive pulmonary disease. It is important to note that medically treated patients were sicker than the other patients. Another significant note is that patients were treated off-label with endothelin receptor antagonist or phosphodiesterase-5 inhibitor. The long-term effects of the recently improved drug needs to be further evaluated to see if this could lead to more problems down the road.

While reading this it made me realize that it is very difficult to tell what a medication will do to people over a very long period of time, and it is hard to find this out before many people are already taking it. I wonder what other medications could potentially lead to major problems for patients down the road that we do not know about yet.

Delcroix M, Lang I, Pepke-Zaba J, et al. Long-term outcome of patients with chronic thromboembolic pulmonary hypertension. Circulation. 2016;133:859-71.

Lower verbal intelligence is associated with diabetic complications and slower walking speed in people with Type 2 diabetes: the Maastricht Study

This study was designed to see if there was a correlation between verbal intelligence, Type 2 diabetes, and walking speed.  They had each participant take the Groningen Intelligence Test which tested their vocabulary and then were assigned a score.  This score was then compared to indicators if Type 2 diabetes like A1C and glucose levels.  This vocabulary score was also compared to other diabetic health complications like chronic kidney disease, cardiovascular disease, and neuropathic pain.  Lastly, they assessed this vocabulary score with the speed at which the individual walked.  They tried to minimize confounding variables like age or gender.

In total, only 228 patients were fully assessed on all three tests.  When the verbal score was compared to the indicators of Type 2 diabetes (A1C, LDL, glucose, etc.) there was no association between the two.  The verbal score was also not associated with kidney disease.  Lower verbal scores did show an association with increased cardiovascular disease and neuropathic pain and decreased walking speed.

They noted that the lower verbal intelligence might be correlated with some diabetic functions because they aren’t as educated and have a lesser understanding of their disease state.  But I’d like to pose the question that if they don’t understand their disease state, then why isn’t there a correlation between low intelligence and out-of-range A1C, LDL, etc.  I also wonder why low intelligence was associated with slower walking.  It would be very interesting to see why exactly they chose to compare these three very different assessments and compared them to each other.  The walking speed especially seems unrelated.


Tang JYM, Wong GHY, Ng CKM, et al. Lower verbal intelligence is associated with diabetic complications and slower walking speed in people with Type 2 diabetes: the Maastricht Study. J Am Geriatr Soc. 10.1111/jgs.13938 (1 March 2016).

Physician Perception of Medication Adherence regarding Medicare

This article details a study that was completed in order to study whether or not physicians truly understood how widespread the lack of adherence there was in their particular patient populations. Non adherence is a rampant problem in the elderly population who are the most common patients who have chronic diseases. Diseases such as hypertension, diabetes, and hyperlipidemia require strong adherence in their therapies in order to achieve the most successful results, and patients can quickly slip out of their goal ranges for the management of their symptoms if they are not on top of taking their daily regimens. The focus of the study was to first determine the physicians’ personal perceptions of their populations’ adherence, and then compare them to the actual data of adherence that were provided by the statistical claims.

The study was completed by the distribution of surveys to primary care physicians in a Texan MD-PA plan that was covered by Medicare Part D. The questionnaire was given to these 226 doctors at quarterly meetings and they were asked questions along the line of what percentage of their patients did they believe were adherent in the medication regimens, what income bracket did the most adherent people come from, etc. The study concluded that primary care physicians were equally likely to both underestimate, or overestimate how adherent their population was.

Overall, I do not believe that this article is very important to the field of pharmacy. First off, this is just a qualitative survey that was given to the doctors, so the whole thing was based on personal opinions. Without a source of hard data, this study cannot prove much on its own. I also believe that adherence changes drastically based upon the environment, so completing this survey in only one health system would not provide a good overview for physicians’ opinions on adherence on the grand scale.
J Manag Care Spec Pharm, 2016 Mar;22(3):305-312.

Sudden death associated with silent myocardial infarction in a 35-year-old man: a case report.

Silent Myocardial Infarction (SMI) is really a heart attack that can happen at any age and at any time without any real warning signs. This article looked at a case report for a 35 year old male that passed unexpectedly. Upon further evaluation of the autopsy report, SMI proved to be the cause of death for this particular individual. The most common risk factors for SMI include smoking history, family history of heart disease, age, high cholesterol, high blood pressure, diabetes, and being overweight. Although it is found that SMI does occur in “2-4% of young adult asymptomatic men.” Cases like this one seem to be heavily underreported due to the asymptomatic aspect of the disease. The most important piece of conclusion from this case study mentioned that this case should be seen as a valuable reminder of SMI for clinicians and pathologists. Education is key in preventing SMIs and other well-known chronic conditions. It is possible that this patient ignored chest pain days prior to the incident. It’s possible that previous education on cardiovascular events might have led this patient to seek medical attention. As healthcare providers how can we best educate our patients on different disease states? We have a health fair in the near future that will include a wide range of information. What is the best method for teaching the most valuable information in order to save lives? Preventative medicine is essential thanks to our increased knowledge of many chronic disease states and should not be ignored.

Aghdam M, Vodovnik A, Sund B. Sudden death associated with silent myocardial infarction in a 35-year-old man: a case report. J Med Case Rep. 2016; 10:46.


Psychomotor effects, pharmacokinetics and safety of the orexin receptor antagonist suvorexant administered in combination with alcohol in healthy subjects

Sleep aids have a storied and often rocky relationship with alcohol. Many are known to have adverse effects when taken with alcohol, and this relationship is important to study because people most commonly consume alcohol around bedtime. This study focuses on how the orexin receptor antagonist, suvorexant, interacts with alcohol.

The study showed that suvorexant when used with alcohol reduces reaction times and cognitive function. Suvorexant and alcohol have an adverse reaction and should not be used together. Basically, alcohol enhances the effects of suvorexant to unsafe levels. However, suvorexant is shown to be perfectly safe when taken as directed.

This study illustrates the need to consider how drugs interact with the things that we ingest besides prescription medications. Alcohol is known to cause adverse effects when used with certain prescription medications, and it is always a good point to remind patients to be careful about alcohol use whenever necessary.

Sun H, Yee KL, Gill S, et al. Psychomotor effects, pharmacokinetics and safety of the orexin receptor antagonist suvorexant administered in combination with alcohol in healthy subjects. J Psychopharmacol. 2015: 29(11): 1159-1169.

On Prions Proteasomes and Mad Cows

The ability of a cell to degrade misfolded proteins, or discard proteins which are no longer useful is essential to the integrity of the cell.  These unwanted proteins can occur or develop naturally, as they may be the product of errors in transcription, mutation, failure to fold correctly, or spontaneous degeneration.  The normal pathway responsible for the effective removal of abnormal proteins is the ubiquitin-proteasome pathway, which utilizes a protein specific tagging system facilitated by ubiquitin, having proteasome degrade the enzyme.  Upon onset, many diseases are identified to posses attributes which increase the amounts of ubiquitin tagged proteins that have not been degraded, or an increase in untagged, and abnormal proteins indicating a failure in the ubiquitin proteasome system entirely.  The diseases associated are cystic fibrosis, amyotrophic lateral sclerosis, Parkinson’s, Lewy-body dementia, Huntington’s disease, and Alzheimer’s.

The mechanism by which these proteins inhibit adequate function in cells remains unclear, yet it is assumed that the proteolytic system is somehow inhibited to allow the buildup of these amyloid proteins. Kristiansen et al has reported evidence that a form of prion disease may be caused by an inhibition of the 26S proteasome. The diseases typically associated are spongiform encephalopathy, creutzfeldt-jacob syndrome, and kuru. These diseases are caused by a toxic prion protein which changes the conformation of the proteasome responsible for degrading abnormal proteins. When this occurs the function of three of the processes associated with the proteasome are inhibited.  It is shown that cells have the ability to regenerate normal proteasome activity if the toxic prion is removed.

The ubiquitin-proteasome pathway has shown to be an integral component of cell signaling networks, and metabolic pathways.  For that reason it has been the selected target of the anticancer drug bortezomib, which is widely used for treatment of Melanoma. This is the target of this drug as the cancer seems to be widely dependent upon proteasomes for survival. It does not inhibit neural function however since it does not cross the blood brain barrier.

N Engl J Med 2007; 357:1150-1152September 13, 2007