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Inhalers used incorrectly at least one-third of time
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: What are the most common errors in inhaler use over the past 40 years?
Background: One of the reasons for poor asthma and COPD control is incorrect inhaler use. Problems with technique have been recognized since the launch of the metered-dose inhaler (MDI) in the 1960s. Multiple initiatives have been implemented, including the design of the dry powder inhaler (DPI); however, problems persist despite all corrective measures.
Study design: Meta-analysis.
Synopsis: The most frequent MDI errors were lack of initial full expiration (48%), inadequate coordination (45%), and no postinhalation breath hold (46%). DPI errors were lower, compared with MDI errors: incorrect preparation (29%), no initial full expiration before inhalation (46%), and no postinhalation breath hold (37%).
The overall prevalence of correct technique was the same as poor technique (31%). There was no difference in the rates of incorrect inhaler use between the first and second 20-year periods of investigation.
Bottom line: Incorrect inhaler use in patients with asthma and COPD persists over time despite multiple implemented strategies.
Citation: Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team. Systematic review of errors in inhaler use: has the patient technique improved over time? Chest. 2016;150(2):394-406.
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Blood thinning with bioprosthetic valves
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does anticoagulation prevent thromboembolic events in patients undergoing bioprosthetic valve implantation?
Background: The main advantage of bioprosthetic valves, compared with mechanical valves, is the avoidance of long-term anticoagulation. Current guidelines recommend the use of vitamin K antagonist (VKA) during the first 3 months after surgery, which remains controversial. Two randomized controlled trials (RCTs) showed no benefit of using VKA in the first 3 months; however, other studies have reported conflicting results.
Study design: Meta-analysis and systematic review.
Setting: Multicenter.
Synopsis: This meta-analysis included two RCTs and 12 observational studies that compared the outcomes in group I (VKA) versus group II (antiplatelet therapy/no treatment). There was no difference in thromboembolic events between group I (1%) and group II (1.5%), but there were more bleeding events in group I (2.6%) versus group II (1.1%). In addition, no differences in all-cause of mortality rate and need for redo surgery were found between the two groups.
Bottom line: The use of VKA in the first 3 months after a bioprosthetic valve implantation does not decrease the rate of thromboembolic events or mortality, but it is associated with increased risk of major bleeding.
Citation: Masri A, Gillinov M, Johnston DM, et al. Anticoagulation versus antiplatelet or no therapy in patients undergoing bioprosthetic valve implantation: a systematic review and meta-analysis [published online ahead of print Aug. 3, 2016]. Heart. doi: 10.1136/heartjnl-2016-309630
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Instability of INRs
Clinical question: Does an initial stable international normalized ratio (INR) predict long-term stability?
Background: Warfarin decreases stroke risk among patients with atrial fibrillation; however, it interacts with food and drugs and requires monitoring to achieve a therapeutic INR. It is unclear if patients on warfarin with an initial stable INR value remain stable over time. Additionally, it is controversial whether patients on warfarin with previously stable INRs should benefit from switching to a non–vitamin K oral anticoagulant.
Study design: Retrospective study.
Setting: Outpatient clinics.
Synopsis: Data were collected from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Included in the study were patients taking warfarin at baseline with three or more INR values in the first 6 months and six or more INR values in the subsequent year. Stability was defined as 80% or more INRs in therapeutic range (2.0-3.0).
Only 26% of patients taking warfarin had a stable INR during the first 6 months, and only 34% continued to have a stable INR in the subsequent year.
Bottom line: Initial stable INR within the first 6 months among patients taking warfarin does not predict long-term INR stability in the subsequent year.
Citation: Pokorney SD, Simon DN, Thomas L, et al. Stability of international normalized ratios in patients taking long-term warfarin therapy. JAMA.2016;316(6):661-663
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does an initial stable international normalized ratio (INR) predict long-term stability?
Background: Warfarin decreases stroke risk among patients with atrial fibrillation; however, it interacts with food and drugs and requires monitoring to achieve a therapeutic INR. It is unclear if patients on warfarin with an initial stable INR value remain stable over time. Additionally, it is controversial whether patients on warfarin with previously stable INRs should benefit from switching to a non–vitamin K oral anticoagulant.
Study design: Retrospective study.
Setting: Outpatient clinics.
Synopsis: Data were collected from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Included in the study were patients taking warfarin at baseline with three or more INR values in the first 6 months and six or more INR values in the subsequent year. Stability was defined as 80% or more INRs in therapeutic range (2.0-3.0).
Only 26% of patients taking warfarin had a stable INR during the first 6 months, and only 34% continued to have a stable INR in the subsequent year.
Bottom line: Initial stable INR within the first 6 months among patients taking warfarin does not predict long-term INR stability in the subsequent year.
Citation: Pokorney SD, Simon DN, Thomas L, et al. Stability of international normalized ratios in patients taking long-term warfarin therapy. JAMA.2016;316(6):661-663
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.
Clinical question: Does an initial stable international normalized ratio (INR) predict long-term stability?
Background: Warfarin decreases stroke risk among patients with atrial fibrillation; however, it interacts with food and drugs and requires monitoring to achieve a therapeutic INR. It is unclear if patients on warfarin with an initial stable INR value remain stable over time. Additionally, it is controversial whether patients on warfarin with previously stable INRs should benefit from switching to a non–vitamin K oral anticoagulant.
Study design: Retrospective study.
Setting: Outpatient clinics.
Synopsis: Data were collected from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Included in the study were patients taking warfarin at baseline with three or more INR values in the first 6 months and six or more INR values in the subsequent year. Stability was defined as 80% or more INRs in therapeutic range (2.0-3.0).
Only 26% of patients taking warfarin had a stable INR during the first 6 months, and only 34% continued to have a stable INR in the subsequent year.
Bottom line: Initial stable INR within the first 6 months among patients taking warfarin does not predict long-term INR stability in the subsequent year.
Citation: Pokorney SD, Simon DN, Thomas L, et al. Stability of international normalized ratios in patients taking long-term warfarin therapy. JAMA.2016;316(6):661-663
Dr. Florindez is an assistant professor at the University of Miami Miller School of Medicine and a hospitalist at University of Miami Hospital and Jackson Memorial Hospital.