Swimming-induced pulmonary edema: pathophysiology and risk reduction with sildenafil.

Swimming-Induced Pulmonary Edema (SIPE) is an effect that some individuals experience after being submerged in surface water. Symptoms include cough, difficulty breathing, coughing up of blood, and low blood-oxygen concentration. One study suggests that SIPE arises because blood moves away from the extremities and into the central veins when the individual is submerged. Colder water exacerbates the effect. Some risk factors for SIPE include higher blood volume, higher venous tone, impaired left ventricular systole function, and low diastolic left ventricular compliance. Essentially, individuals with more blood, veins that are less able to account for the blood that is displaced from the legs, and decreased left ventricular function are more susceptible to experience symptoms of SIPE.
This study measured the effects of sildenafil on increased pulmonary arterial pressure resulting from water based exercise. Ten subjects that were previously known to be susceptible to SIPE and 20 control subjects exercised for 6-7 minutes in 20 degrees Celsius water. The SIPE individuals were given 50 mg sildenafil. After 150 minutes, they repeated the exercise. Catheters were placed in the radial and pulmonary arteries to measure arterial pressure. They found that the sildenafil reduced pulmonary vasculature pressures and may be useful in preventing SIPE.

Moon RE, Martina SD, Peacher DF, et al. Swimming-induced pulmonary edema: pathophysiology and risk reduction with sildenafil. AHA. doi: 10.1161/CIRCULATIONAHA.115.019464 (published 16 February 2016).
Further studies should be completed before the drug is recommended for SIPE prevention. A study could measure how sildenafil effects exercise performance. Another study could measure the side effects of sildenafil when used for SIPE prevention (most individuals using it for this indication are young and healthy). Viagra is also very expensive and not yet available as a generic. How will insurance companies decide whether or not to cover the drug for this indication? From a pharmacist’s standpoint, how can we counsel patients who are using sildenafil for SIPE prevention who are typically young and healthy individuals?

Influences of diabetes on hearing recovery in noise-exposed mice

Diabetes is a disease that affects the microvasculature. This in turn affects other systems of the body such as the renal, visual, and peripheral nervous systems. Many studies have focused on the effect of diabetes on hearing. Diabetes can interfere with the supply of blood to the cochlea or the 8th cranial nerve, causing degeneration. However, these studies have shown correlations between diabetes and hearing loss rather than causations according to a study published in the Journal of Audiology and Otology. This study specifically measured the effect of diabetes on the hearing of mice compared to that of normal mice. In order to measure the degree of hearing loss due to age, the hearing threshold of 5 week old mice with and without diabetes were measured. In order to measure the effect of diabetes on hearing recovery, 5 week old mice with and without diabetes were exposed to broad band white noise 110 dB for 3 hours. The hearing threshold of these mice were measured before exposure and 1, 3, and 5 days and 2, 3, and 4 weeks following. There was no significant difference between the hearing thresholds of diabetic and non-diabetic mice in hearing recovery. However, there was a significant difference between the hearing thresholds in diabetic and non-diabetic mice due to aging.

J Audiol Otol. 2015 Dec; 19(3):138-143.

Further studies should be conducted to measure even longer-term effects of diabetes on hearing. The applicability of the study to humans could be studied as well as possible methods of prevention. I think this study is important for pharmacists to know because it adds another counseling point for when we talk to patients with diabetes. Additionally, we can be aware of the population we are serving by understanding that they may not be able to hear us as well as someone their age without diabetes.

Lifestyle modification and weight reduction among low-income patients with the metabolic syndrome: the CHARMS randomized controlled trial

Metabolic syndrome is defined by the following risk factors: abdominal obesity, elevated blood pressure, dyslipidemia, abnormal glucose regulation. Prolonged metabolic syndrome increases a persons risk of developing cardiovascular disease and type 2 diabetes. As we have learned a lot during our first and second semesters of pharmacy school, not all populations have equal risk of developing diseases. Many are determined by socioeconomic status. Vulnerable populations to metabolic syndrome include the Hispanic population and those with lower socioeconomic status including education and household income. This study aimed to assess the efficacy of lifestyle interventions to reduce the rate and severity of metabolic syndrome in these populations. They recruited low income, minority participants (less than $20,000). The participants must have 3 of the following: high waist circumference, high triglyceride levels, high HDL levels, hypertension, and impaired fasting glucose to be considered to have metabolic syndrome. The interventions were tailored to the community by translating the educational materials to Spanish, delivering the healthcare meetings in Spanish should the patient be comfortable with that, and providing culturally relevant examples and dietary recommendations. Overall the intervention showed a significant reduction in weight especially in female participants. Additionally the fasting blood glucose level was significantly reduced. There was no reduction in cholesterol, abdominal obesity, or number of patients qualifying for metabolic syndrome. The educational materials being translated showed an effect on how well the materials were received.

J Behav Med. doi: 10.1007/s10865-016-9721-2 (published 04 February 2016).

This study shows just how important it is to keep the community we serve in mind when creating treatments for patients. Healthcare and treatment regimens are not universal, as we see in guidelines like JNC 8 where certain populations are given different treatments for hypertension. Further studies could be done to emphasize the importance of creating differential treatments for patients for all kinds of disease states according to population.

Interactive effects of physical fitness and body mass index on the risk of hypertension

A cohort study with Sweden was conducted over a long duration of time. They measured the aerobic capacity, muscular strength, and body mass index during military consignment evaluations in Sweden from 1969 to 1997. This accounts for 97% of 18 year old men in Sweden during that duration of time. The researchers performed follow-up evaluations of these patients in 2012 to measure their degree of hypertension. The study measures the correlation between aerobic capacity, muscular strength, and body mass index in late adolescence and the degree of hypertension in adulthood. The results showed that high body mass index and low aerobic capacity combined posed the highest risk of developing hypertension later in life. In patients with normal body mass index, a low aerobic capacity still posed a significant risk of developing hypertension. All statistics were adjusted for socioeconomic status and family history.

JAMA Intern Med. 2016;176(2):210-216.
I think this research is important because it shows that patients can intervene at a young age to prevent disease states like hypertension later in life. It demonstrates that diseases, even ones that seem to be hereditary like hypertension, are not always inevitable. We can take action now to lower our risk.
I think further research should be done to measure how aerobic capacity, muscular strength, and body mass index affect risk of developing hypertension in women, as well as other ethnicities.

A comparative effectiveness trial of alternate formats for presenting benefits and harms information for low-value screening services

A study connected with Duke Primary Care Research Consortium tested the effectiveness of multiple methods of presenting the harms and benefits of certain “low-value” screenings. These include tests that do not pose benefits that outweigh the harms and costs. This can cause physical and financial harms with no foreseeable benefit for the patient and the industry. In the study, each patient of 775 individuals was presented with information regarding the risks and benefits of 1 of 3 tests including prostate cancer screenings, osteoporosis screenings, and colorectal cancer screenings. The information was presented either by numbers, words, numbers with a narrative, or numbers with a framed presentation. They measured the change of the patients’ intention of receiving the screening. All patients were intending on receiving the screening before the intervention was administered. Change of intention was very low and similar among all interventions tested.

JAMA Intern Med. 2016;176(1):31-41.

 

I understand that the benefit of screenings for diseases like colorectal cancer may not outweigh the costs and harms for some patients. However in cases like cancer, early detection may save the patients life. I think that is worth the chance of getting a negative result every time.
I think it is interesting that we are trying to persuade patients to not look into their health. Typically, as healthcare providers, we want patients to have as much information as possible about their body and health status.
The trial suggests that alternative interventions for presenting this information should be considered. What other interventions do you think could persuade the patient from receiving the screening?

Prescription strategies to reduce antibiotic use while controlling symptoms of acute respiratory infections

This study measured symptom duration and severity in patients with acute respiratory infections when given different methods of obtaining antibiotics. One group was given antibiotics and instructed to start their therapy that day. Another group was given no antibiotics. A third group was given a prescription for antibiotics but instructed to only take them if their symptoms do not improve within 3-5 days. The last group was told to pick up a prescription for antibiotics from the physician’s front desk only if their symptoms do not improve within 3-5 days. For each patient, the physician decided which antibiotic would best treat the patient’s respiratory infection. The results showed that the groups with delayed strategies had longer duration of symptoms but reduced use of antibiotics.

JAMA Intern Med. 2016;176(1):21-29.

 

Because this trial did not focus on a specific acute respiratory infection, it is difficult to determine the consequences of delaying treatment. I know for some infections, delaying treatment may have negative consequences for the patient. I think it is important to realize that the physician has more medical knowledge than the patient. While the patient’s point of view and belief in effectiveness of treatments like antibiotics is important in creating the right treatment regimen, in the delayed strategy, whether or not the patient even starts that treatment is in their hands. The physician should be doing more to advocate to improve the patient’s quality of life.

Community pharmacist screening for chronic kidney disease

The authors conducted this study as a part of the RxEACH study, which assesses reduction of cardiovascular risk intervention versus usual care as led by pharmacists. This part of the study analyzed pharmacists’ application of the CKD Clinical Pathway criteria (which is an online tool to aid practitioners in diagnosis and management of those with CKD) to screen their patients who are at risk for chronic kidney disease. CKD is defined as a reduction in kidney function with a GFR less than 60 mL/min/1.73m^2 or markers of kidney damage for more than 3 months. Markers of kidney damage includes albuminaria greater than 3 mg/mmol or any abnormalities in urine sediment or renal imaging. The pharmacists systematically identified patient based on their prescriptions (looking for oral hypoglycemic, antihypertensives, lipid-lowering, antiplatelet, and anticoagulants). They also checked the patient’s lab values. Once a patient iss eligible, the patient was screened based on serum creatinine, GFR, and urine albumin-to-creatinine for 12 months. Patients were categorized into the following: no CKD, known CKD, and unrecognized CKD. Of the 720 patients, 60% had known CKD. Forty percent of those with CKD had unrecognized CKD. Overall, the study identified a high number of unrecognized CKD patients, emphasizing the importance of expanding the pharmacist’s role to include laboratory testing and adjusting medication regimens according to those results. Because the study was conducted on patients with a high risk for cardiovascular disease, the results may be higher than in an otherwise healthy population.

Can Pharm J. 2016;149(1):13-17.
I think this study really shows the healthcare world just how important the role of the pharmacist is. We are more than just dispensers. We can optimize a patient’s medication regimen based on the health of their kidneys. Additionally, we can identify patients at risk for chronic kidney disease that a physician may otherwise not have diagnosed. In addition to screening patients for CKD, what other disease may a pharmacist be able to screen for? How can we as student pharmacists advocate for the expansion of the role of the pharmacist to include these screenings at all pharmacy locations?

Adherence to preventative HIV infection therapies

Several studies have shown that actions to prevent HIV infection prior to exposure reduce HIV infection in men who have sex with men and transgender women by 44%. These preventative actions include tenofovir disoproxil fumarate and emtricitabine oral drug therapies. This study assessed adherence to these therapies, sexual behaviors, and STI and HIV infection in men who have sex with men and transgender women in STI clinics in San Francisco, Miami, and Washington, D.C. They tested the blood concentration of the drugs, number of sex partners, instances of unsafe sex, and HIV infection. At follow-up visits, 80% of participants had levels of the drug that would be sufficient to protect them from infection. African American populations and those in Miami were less likely to have sufficient blood concentration. Populations with stable housing and those who had more than two unsafe sex partners within the last three months were more likely to have sufficient blood concentration. The study concluded that the more a participant acts on risky behaviors, the more likely they are to be adherent to the preventative therapies.

I was pleasantly surprised by the results of the study. I was expecting the people who have risky behaviors to be less inclined to prevent infection simply because they were participating in the risky behaviors. It bodes well in regards to the HIV epidemic that these people are working to prevent infection, though in a perfect world, all people participating in these behaviors would be adherent to preventative therapies.

 

JAMA Intern Med. 2016;176(1):75-84.