Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction

BACKGROUND: Heart failure is associated with high mortality and hospital readmissions. Beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) can improve survival and reduce hospital readmissions and are recommended as first-line therapy in the treatment of heart failure. Evidence has also shown that there is a dose-dependent relationship of these medications with patient outcomes. Despite this evidence, primary care physicians are reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration (NLT) is one such strategy. OBJECTIVES: To assess the effects of NLT of beta-adrenergic blocking agents, ACEIs, and ARBs in patients with heart failure with reduced ejection fraction (HFrEF) in terms of safety and patient outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL Issue 11 of 12, 19/12/2014), MEDLINE OVID (1946 to November week 3 2014), and EMBASE Classic and EMBASE OVID (1947 to 2014 week 50). We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources. We used no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing NLT of beta-adrenergic blocking agents, ACEIs, and/or ARBs comparing the optimisation of these medications by a nurse to optimisation by another health professional in patients with HFrEF. DATA COLLECTION AND ANALYSIS: Two review authors (AD & JC) independently assessed studies for eligibility and risk of bias. We contacted primary authors if we required additional information. We examined quality of evidence using the GRADE rating tool for RCTs. We analysed extracted data by risk ratio (RR) with 95% confidence interval (CI) for dichotomous data to measure effect sizes of intervention group compared with usual-care group. Meta-analyses used the fixed-effect Mantel-Haenszel method. We assessed heterogeneity between studies by Chi(2) and I(2). MAIN RESULTS: We included seven studies (1684 participants) in the review. One study enrolled participants from a residential care facility, and the other six studies from primary care and outpatient clinics. All-cause hospital admission data was available in four studies (556 participants). Participants in the NLT group experienced a lower rate of all-cause hospital admissions (RR 0.80, 95% CI 0.72 to 0.88, high-quality evidence) and fewer hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72, moderate-quality evidence) compared to the usual-care group. Six studies (902 participants) examined all-cause mortality. All-cause mortality was also lower in the NLT group (RR 0.66, 95% CI 0.48 to 0.92, moderate-quality evidence) compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving NLT of beta-adrenergic blocking agents, ACEIs, and ARBs. Only three studies (370 participants) reported outcomes on all-cause and heart failure-related event-free survival. Participants in the NLT group were more likely to remain event free compared to participants in the usual-care group (RR 0.60, 95% CI 0.46 to 0.77, moderate-quality evidence). Five studies (966 participants) reported on the number of participants reaching target dose of beta-adrenergic blocking agents. This was also higher in the NLT group compared to usual care (RR 1.99, 95% CI 1.61 to 2.47, low-quality evidence). However, there was a substantial degree of heterogeneity in this pooled analysis. We rated the risk of bias in these studies as high mainly due to a lack of clarity regarding incomplete outcome data, lack of reporting on adverse events associated with the intervention, and the inability to blind participants and personnel. Participants in the NLT group reached maximal dose of beta-adrenergic blocking agents in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event. AUTHORS' CONCLUSIONS: Participants in the NLT group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting NLT as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions. Despite evidence of a dose-dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving outcomes in patients with HFrEF, the translation of this evidence into clinical practice is poor. NLT is one strategy that facilitates the implementation of this evidence into practice.

Clinical pharmacology of dipeptidyl peptidase 4 inhibitors indicated for the treatment of type 2 diabetes mellitus

Dipeptidyl peptidase-4 (DPP-4) inhibitors are a class of oral antidiabetic drugs that improve glycaemic control without causing weight gain or increasing hypoglycaemic risk in patients with type 2 diabetes mellitus (T2DM). The eight available DPP-4 inhibitors, including alogliptin, anagliptin, gemigliptin, linagliptin, saxagliptin, sitagliptin, teneligliptin, and vildagliptin, are small molecules used orally with identical mechanism of action and similar safety profiles in patients with T2DM. DPP-4 inhibitors may be used as monotherapy or in double or triple combination with other oral glucose-lowering agents such as metformin, thiazolidinediones, or sulfonylureas. Although DPP-4 inhibitors have the same mode of action, they differ by some important pharmacokinetic and pharmacodynamic properties that may be clinically relevant in some patients. The main differences between the eight gliptins include: potency, target selectivity, oral bioavailability, elimination half-life, binding to plasma proteins, metabolic pathways, formation of active metabolite(s), main excretion routes, dosage adjustment for renal and liver insufficiency, and potential drug-drug interactions. The off-target inhibition of selective DPP-4 inhibitors is responsible for multiorgan toxicities such as immune dysfunction, impaired healing, and skin reactions. As a drug class, the DPP-4 inhibitors have become accepted in clinical practice due to their excellent tolerability profile, with a low risk of hypoglycaemia, a neutral effect on body weight, and once-daily dosing. It is unknown if DPP-4 inhibitors can prevent disease progression. More clinical studies are needed to validate the optimal regimens of DPP-4 inhibitors for the management of T2DM when their potential toxicities are closely monitored.

Relative toxicity of selective serotonin reuptake inhibitors (SSRIs) in overdose

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) have increasingly replaced tricyclic antidepressants (TCAs) in the treatment of depression. They appear to be safer in overdose, but there is little information on their spectrum of toxicity in overdose, or relative toxicity of each agent. OBJECTIVE: To determine the effect of SSRIs in overdose, as a group, and the relative toxicity of five different SSRIs. METHODS: A review of consecutive SSRI poisoning admissions to a single toxicology unit. Outcomes examined were length of stay [LOS], intensive care [ICU] admission rate, coma, seizures, electrocardiographic [ECG] abnormalities, and presence of serotonin syndrome [SS]. Logistic regression was used to model the outcome QTc >440 msec. RESULTS: There were 469 SSRI poisoning admissions analyzed after exclusions. The median LOS for all SSRI overdose admissions was 15.3 h (IQR: 10.5-21.3) and 30 of 469 (6.4%; 95% CI 4.3-9.0%) cases were admitted to ICU. The incidence of seizures was 1.9% and coma was 2.4%. Serotonin syndrome occurred in 14% of overdoses. Comparison of median QTc intervals of the five SSRIs was significantly different (p=0.0002); citalopram (450 IQR: 436-484) was individually different to fluoxetine (p=0.045), fluvoxamine (p=0.022), paroxetine (p=0.0002), and sertraline (p=0.001). The proportion of citalopram overdoses with a QTc >440 msec was 68%, differing significantly from sertraline (adjusted OR: 5.11 95% CI 2.32-11.27). Comparison of median QT intervals of the five SSRIs was statistically different (p=0.026); citalopram (400 IQR: 380-440) was individually different from sertraline (p=0.023). CONCLUSIONS: This study shows SSRIs are relatively safe in overdose despite serotonin syndrome being common. The exception was citalopram, which was significantly associated with QTc prolongation. We believe that cardiac monitoring should be considered in citalopram overdose, particularly with large ingestions and patients with associated cardiac disease.

Corrosion behaviour and hardness of in situ consolidated nanostructured Al and Al-Cr alloys produced via high-energy ball milling

This paper presents a hypothesis and its experimental validation that simultaneous improvement in the hardness and corrosion resistance of aluminium can be achieved by the combination of suitable processing route and alloying additions. More specifically, the corrosion resistance and hardness of Al- xCr (x= 0-10 wt.%) alloys as produced via high-energy ball milling were significantly higher than pure Al and AA7075-T651. The improved properties of the Al- xCr alloys were attributed to the Cr addition and high-energy ball milling, which caused nanocrystalline structure, extended solubility of Cr in Al, and uniformly distributed fine intermetallic phases in the Al-Cr matrix.

Corrosion protection afforded by praseodymium conversion film on Mg alloy AZNd in simulated biological fluid studied by scanning electrochemical microscopy

Surface passivation of AZNd Mg alloy with Pr(NO3)3 is studied using scanning electrochemical microscopy (SECM) in surface generation/tip collection (SG/TC) and AC modes. Corrosion protection afforded by the Pr treatment and the degradation mechanism in a simulated biological environment was examined on a local scale and compared with non-treated AZNd. SG/TC mode results revealed a drastic decrease in H2 evolution due to the Pr treatment. Mapping the local insulating characteristics using AC-SECM showed higher conductivity of the surface where H2 evolution was most favorable.

Synthesis and anti-corrosion performance of Adenine-L-Alanine ramification

In this paper, a new amino acid derivative, namely Adenine-L-Alanine ramification (ALAR) was synthesized and investigated as a green corrosion inhibitor for X80 pipeline steel in 0.1 mol/L hydrochloric acid solution using the weight loss, AC impedance, and polarization curve method. The structure of the derivative was characterized by IR and UV–vis spectrum. The weight loss and AC impedance found that the inhibition efficiency increased with the increase in concentration of the inhibitor but decreased with rise in temperature, the corrosion inhibition efficiency attains 91.26% in 8 × 10−2 g/L concentration at 30 °C. The polarization studies showed that the studied amino acid derivative can be used as a corrosion inhibitor. The surface of inhibited and uninhibited specimens was analyzed by scanning electron microscopy and the adsorption of the inhibitor on the mild steel surface obeys Langmuir adsorption isotherm. The quantum chemical descriptors such as the energy of highest occupied molecular orbital, energy of lowest unoccupied molecular orbital were calculated and the inhibition mechanism can be analyzed by the distribution of electrons. Analysis indicated that the inhibitor molecular and empty d orbital of metal forms the coordination bond, covers on the surface of metal, and prevents corrosion reaction.

Evaluation of corrosion behaviour of biodegradable base oils using electrochemical techniques

© 2015 Institute of Materials, Minerals and Mining. Published by Maney on behalf of the Institute. This paper describes an interesting attempt to quantitatively evaluate the corrosion behaviour of base oils using a novel approach based on electrochemical techniques. The present study evaluates the corrosion behaviour of biodegradable base oils with and without additives in an aqueous chloride solution using electrochemical measurements. Potentiodynamic polarisation and electrochemical impedance spectroscopy techniques were used to quantitatively determine the corrosion behaviour of these oils, and the results were compared to the conventional immersion tests. Both these electrochemical measurements were carried out in a three-electrode system where AS1020 mild steel alloy was used as a working electrode in a purpose made pipette cell. The results obtained from the electrochemical measurements help to evaluate the best biodegradable base oil for formulating eco-friendly industrial lubricants.

Electrochemically monitoring localized corrosion patterns and CP effectiveness under disbonded coatings

© 2015 by Nace International. This paper presents new experimental evidences on the capability of a novel electrochemical corrosion monitoring sensor, which was recently conceived, for measuring localized corrosion under disbonded pipeline coatings. The sensor's design includes an artificial crevice for simulating the conditions developed under disbonded coatings and an electrode array for measuring current density distribution over its surface. The sensor capabilities were further evaluated by studying the dependency of corrosion patterns and current density distribution on the Cathodic Protection (CP) potential applied upon immersion in an aqueous environment. At the less negative CP potential, a good correlation was found between the inhomogeneous corrosion distribution under the disbonded coating as measured by the sensor and actual metal loss and corrosion attack observed on its surface at the end of the test. At more negative CP potentials no corrosion was detected or observed on the sensor's surface. In addition, characteristic changes in the cathodic current distribution at different CP potentials illustrated the possibility of employing the sensor to obtain valuable feedback on the performance of a given CP setup, without requiring its interruption or compensation of IR-drops. Furthermore, the sensor's capability to detect some of the effects of overprotection were shown at the most negative CP potential applied.

Structural health monitoring: a practical approach to achieving in-situ and site-specific warning of pipeline corrosion and coating failure

An approach to achieving the ambitious goal of cost effectively extending the safe operation life of energy pipelines to, for instance, 100 years is the application of structural health monitoring and life prediction tools that are able to provide long-term remnant pipeline life prediction and in-situ pipeline condition monitoring. A critical step in pipeline structural health monitoring is the enhancement of technological capabilities that are required for quantifying the effects of key factors influencing buried pipeline corrosion and environmentally assisted materials degradation, and the development of condition monitoring technologies that are able to provide in-situ monitoring and site-specific warning of pipeline damage. This paper provides an overview of our current research aimed at developing new sensors for monitoring, categorising and quantifying the level and nature of external pipeline and coating damages under the combined effects of various inter-related variables and processes such as localised corrosion, coating damage and disbondment, cathodic shielding. The concept of in-situ monitoring and site-specific warning of pipeline corrosion is illustrated by a case of monitoring localised corrosion under disbonded coatings using a new corrosion monitoring probe. A basic principle that underpins the use of sensors to monitor localised corrosion has been presented: Localised corrosion and coating failure are not an accidental occurrence, it occurs as the result of fundamental thermodynamic instability of a metal exposed to a specific environment. Therefore corrosion and coating disbondment occurring on a pipeline will also occur on a sensor made of the same material and exposed to the same pipeline condition. Although the exact location of localised corrosion or coating disbondment could be difficult to pinpoint along the length of a buried pipeline, the ‘worst-case scenario’ and high risk pipeline sections and sites are predictable. Sensors can be embedded at these strategic sites to collect data that contain ‘predictor features’ signifying the occurrence of localised corrosion, CP failure, coating disbondment and degradation. Information from these sensors will enable pipeline owners to prioritise site survey and inspection operations, and to develop maintenance strategy to manage aged pipelines, rather than replace them.

Internet share of advertising expenditure : growth drivers and inhibitors in the brazilian market

Os investimentos com publicidade na Internet como uma percentagem das despesas totais de publicidade variam significativamente de um país para outro. O número é tão baixo quanto 4,7% no mercado brasileiro e tão alto como 28,5% no mercado britânico (ZenithOptimedia, 2011b). Algumas razões explicam tal disparidade. No nível macro, a participação dos gastos com publicidade na Internet está fortemente ligada a variáveis como o produto interno bruto per capita e à penetração da Internet na população. No nível micro, uma pesquisa qualitativa foi feita para identificar os fatores que contribuem e inibem o crescimento da participação da publicidade online no mercado brasileiro. A vasta lista de inibidores parece ter profundo impacto sobre como os profissionais de mercado tomar decisões de alocação de investimento em publicidade por tipo de mídia. Devido à legislação, à auto-regulamentação e às dinâmicas da indústria, grande parte da tomada de decisão é realizada por agências de publicidade. Estas parecem ter fortes incentivos econômicos para selecionar outros tipos de mídia e não a Internet ao definir planos de mídia. Ao mesmo tempo, a legislação e a auto-regulamentação fornecem desincentivos para corretores de mídia a operar no mercado local. A falta de profissionais qualificados e a padronização limitada também desempenham papéis importante para inibir uma maior participação da Internet nos gastos com publicidade no Brasil. A convergência dos resultados quantitativos com os qualitativos indica possíveis motivos pelos quais a participação da publicidade online no Brasil é tão baixa. Em primeiro lugar, a participação é explicada pelo estágio de desenvolvimento dos países. Quanto mais rico e mais desenvolvido um país, maior a proporção de gastos com publicidade online tende a ser. Em segundo lugar, o estágio econômico emergente do Brasil potencialmente dá espaço para o aumento do ineficiências do mercado, tais como programas de descontos oferecidos de forma desproporcional para os principais decisores de alocação de investimentos de mídia. Este fato aparentemente produz um feedback negativo, contribuindo para manter a baixa participação da publicidade online no total dos investimentos publicitários.

Avaliação da espécie vegetal Croton cajucara Benth como inibidor de biocorrosão em aço carbono Aisi 1020

Actually in the oil industry biotechnological approaches represent a challenge. In that, attention to metal structures affected by electrochemical corrosive processes, as well as by the interference of microorganisms (biocorrosion) which affect the kinetics of the environment / metal interface. Regarding to economical and environmental impacts reduction let to the use of natural products as an alternative to toxic synthetic inhibitors. This study aims the employment of green chemistry by evaluating the stem bark extracts (EHC, hydroalcoholic extract) and leaves (ECF, chloroform extract) of plant species Croton cajucara Benth as a corrosion inhibitor. In addition the effectiveness of corrosion inhibition of bioactive trans-clerodane dehydrocrotonin (DCTN) isolated from the stem bark of this Croton was also evaluated. For this purpose, carbon steel AISI 1020 was immersed in saline media (3,5 % NaCl) in the presence and absence of a microorganism recovered from a pipeline oil sample. Corrosion inhibition efficiency and its mechanisms were investigated by linear sweep voltammetry and electrochemical impedance. Culture-dependent and molecular biology techniques were used to characterize and identify bacterial species present in oil samples. The tested natural products EHC, ECF and DCTN (DMSO as solvent) in abiotic environment presented respectively, corrosion inhibition efficiencies of 57.6% (500 ppm), 86.1% (500 ppm) and 54.5% (62.5 ppm). Adsorption phenomena showed that EHC best fit Frumkin isotherm and ECF to Temkin isotherm. EHC extract (250 ppm) dissolved in a polar microemulsion system (MES-EHC) showed significant maximum inhibition efficiency (93.8%) fitting Langmuir isotherm. In the presence of the isolated Pseudomonas sp, EHC and ECF were able to form eco-compatible organic films with anti-corrosive properties

Diapocynin versus apocynin as pretranscriptional inhibitors of NADPH oxidase and cytokine production by peripheral blood mononuclear cells

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Corrosion behavior of Ti-13Nb-13Zr alloy used as a biomaterial

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Powder Diffraction of Components Subject to Corrosion in Fuse Cutouts with CeramicInsulation

Aiming identification of the components most affected by corrosion under saline environment conditions, we have carried out X-ray diffraction measurements in ceramic and bond materials, all in the powder form. The ceramic is analyzed before and after thermal annealing at 1000 degrees C, showing the same DRX peaks, although better defined after annealing. Identification suggests the presence of Al(6)Si(2)O(13) (Mullite) and SiO(2) (Quartz). Analysis of the junction (bond) material shows similar peaks, but a metallic preponderance is observed. Thermal annealing of the junction is done at much lower temperature, because it melts in the range 135 degrees C-170 degrees C, when a whitish smoke begins to show up along with strong sulfur odor.

Corrosion behavior of Ti-6Al-4V alloy treated by plasma immersion ion implantation process

Ti-6Al-4V alloy is one of the most frequently used Ti alloys with diverse applications in aerospace and biomedical areas due to its favorable mechanical properties, corrosion resistance and biocompatibility. Meanwhile, its surface can stiffer intense corrosion caused by wear processes due to its poor tribological properties. Thus in the present study, PIII processing of Ti-6Al-4V alloy was carried out to evaluate its corrosion resistance in 3.5% NaCl solution. Two different sets of Ti-6Al-4V samples were PIII treated, varying the plasma gases and the treatment time. The corrosion behavior is correlated with the surface morphology, and the nitrogen content. SEM micrographs of the untreated sample reveal a typical two-phase structure. PIII processing promotes surface sputtering and the surface morphology is completely different for samples treated with N-2/H-2 mixture and N-2 only. The highest penetration of nitrogen (similar to 88 nm), corresponding to 33% of N-2 was obtained for the sample treated with N-2/H-2 mixture for 1:30 h. The corrosion behavior of the samples was investigated by a potentiodynamic polarization method. A large passive region of the polarization curves (similar to 1.5 V), associated with the formation of a protective film, was observed for all samples. The passive current density (similar to 3 x 10(-6) A cm(-2)) of the PIII-treated Ti-6Al-4V samples is about 10 times higher than for the untreated sample. This current value is still rather low and maintains good corrosion resistance. The anodic branches of the polarization curves for all treated Ti-6Al-4V samples demonstrate also that the oxide films break down at approximately 1.6 V, forming an active region. Although the sample treated by N-2/H-2 mixture for 1.30 It has thicker nitrogen enriched layer, better corrosion resistance is obtained for the PIII process performed with N, gas only. (c) 2007 Elsevier B.V. All rights reserved.