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    10 views5 pages

    Varicella Vaccine and Shingles

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    Agus P

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    © All Rights Reserved
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    of 5
    im LETTERS Treatment of Congestive Heart Failure ‘To the Editor: In their Scientific Review article about treat- ‘ment of advanced heart failure, Dr Nohria and colleagues! do not discuss relief of dyspnea by administration of low-dose nar- ‘The literature in hospice and palliative care has numerous citations about the usefulness of narcotics for palliation of symptoms." I have found that some patients have dramatic relief of their symptoms and commonly ask why previous physicians did not offer this simple treatment with its dra- ‘matic results, Patient and family education about disease ‘management along with successful advance planning allows patients with advanced heart failure to be treated effectively at home, As a final note, since advanced heart disease isa fatal ill- ‘ness, [also encourage physicians to initiate discussions about advance care planning to ensure that patients receive care that fs consistent with their wishes, Richard D. Brumley, MD Southern California Permanente Medical Group Downey 4. Noa. A Leis Stevenson LW. Mia management of svanced est fa Ue Janta, 2002287 698-640 2" Weisman O. Dyspnea at nd-o Lite. Milwaukee: End-of-Life Physician Edu {aon Resource Cente, Hsia Colege of Wscorsr.Noverber 2000. Fst Fact ang Concept No. 27 Avaliable at hp epere mow ed, Accee Sbityverfled Apa 5 Galanos A Lag txm caren genie. Cin Fm Pract. 2001 3:683-694, 4, FeangerG, Ber Hear faire nthe ela, ins n genatre meine donor, ‘To the Editor: In their Scientific Review article about the ‘management of advanced heart failure, Dr Nohria and col- leagues! suggested that angiotensin Il receptor blockers (ARBs) are a reasonable alternative for patients who cannot tolerate angiotensin converting enzyme (ACE) inhibitors because of severe cough or angioedema. Although we agree that ARBs, or a combination of hydralazine and a nitrate, con- stitute a reasonable alternative in patients experiencing persis- tent cough associated with receiving ACE inhibitors, we believe that ARBs in patients with a history of an ACE inhibitor-associated angioedema should only be used with extreme caution, if at all ACE inhibitor-associated angioedema ean occur hours to yeats following drug initiation. The mechanism of ACE in- Ihibitor-associated angioedema has not been completely elu- cidated. Some have stggested that this adverse drug reaction is secondary to the inhibition of bradykinin metabolism and accumulation, resulting from ACE inhibition, although other proposed mechanisms include release of histamine, substance P, and prostaglandin.”* Black patients are at particular risk for developing angioedema, Although others have also recom- (©2002 American Medical Association, All rights reserved, mended ARBs in patients previously experiencing ACE inbibt- tor-associated angioedema,’ recent data have questioned the safety ofthis practice ** Morcover, an analysis of published cases indicated that in 32% of patients with ARB-associated angio- ‘edema had a history of ACE inhibitor-associated angio- ‘edema.* Of even more concerns that in some cases, ARBs were not identified as the responsible agent; thus, continuation of the drug following the first episode resulted in further epi sodes of angioedema? ‘We believe that « combination of hydralazine and a nitrate represents a safer and more appropriate alternative for treat- ment of left ventricular dysfunction in patients with a history ‘of ACE inhibitor induced angioedema, Simon de Denus, MSe(Pharm) Philadelphia Collegeof Pharmacy University of the Seiences in Philadelphia Sarah A. Spinler, PharmD Philadelphia Collegeof Pharmacy University of the Seiences in Philadelphia Department of Medicine, Cardiovascular Section University of Pennsylvania Philadelphia 4. Nha A Lewis Stevenson LW Maia managementof advanced heat re JAMA, 200328708620 2 Wamer Ke, Vso JA Tschampel MM, Angitesin I receptor lockers in patent wth ACE nhibtor-nduedangioedems. Ann Pharmacother. 2000.34 Baeme 5 CHUA, Krowsk 1, Deb Angicedema associate wth angiotensin re ‘por antagonist changing our nowedge of angcncrns ands ey. Lahyngescape, 2001 1111723173 44Vieeming W, van Aster IGC, Sticker BHC, de Wit 0). ACEinitor Induced angoedema, Drug att. 1958, 18.1718 5 Hunt SA, faker DW, Chn MP, etal. ACCIAKA gues fr the evaluation nd management of enone hes fur the ale executive suena are Dato the Anecan Colege of Carclogy/Ameian Hen Astocabon TascForce fn Practice Gudlnes (Commie to ese the 1995 Cudenes for he Evalue ‘tn and Management of Heart Fale). Am Col Cardiol. 2001;38 2107-2113, ‘To the Editor: Dr Nohria and colleagues! provide no evi- dence for their conclusion that heart failure hospital are reliably decreased by experienced heart failure physician- rmarse teams making decisions but not by centralized nursing services providing patient contact but no intervention except ‘GUIDELINES FOR LETTERS. eters iscusing a recent JAMA article should [ereceed witun 4 wees of the are’ publeaon and shoul nat exceed 400 ‘words of text and 5 eterences Letters epring orginal research shoul not x ‘eed 500 word and references Allee sould noude a word count Lees ‘must rot dupbeate other materal published or submitted for pubeaon, Letters ‘ile pubihed athe dacretion the extra pace perm nd ar ube {edtng andabiement Asigned statement or authoshp caters an spor Sify, span dcosure, copyaght Unser, and acknowledgment reuied ‘ocpubatn Letters not meetng thee spectation are ganeaty not cans {Ee tie ill be turd especialy equi Ase a ‘ons fr Authors Uaruay 2, 2002). Lets may be sabre by slate mal Letters Eto JAMA, 515 NSlatest Cheago ILGO61, emal-IAMACettsdama “assorg ofa (please abo send a har copy autem: (312) 648225, ites Secon Ein: ian Lr PhO, Seri Ear 2002Vol 207, No. 17 (Repent) JAMA, sty 2209 Downloaded From: by a London Sch of Hygiene & Tropical Medicine User on 02/28/2018. Terres through multiple primary providers.” We believe thatthe meta- analysis‘they cited in suppor of this conclusion is flawed. One? of the 2 studies in the meta-analysis that was categorized as ‘evaluating telephonic “centralized nursing services” to en hance primary care follow-up did not even focus ona heat fil- ure disease management program. Instead, patients inthe Vet- rans Affairs (VA) health care system with variety of chronic illnesses received global primary care clinician and nursing sup- port. Second, the patients in the VA study had higher comor- bidity and lower baseline quality of life scores than patients in the other studies included in the meta-analysis. Third, the au- thors ofthe VA study acknowledged that many factors unique to the VA system may have influenced their findings and thus ‘would limit their generalizability to other healthcare systems. “The appropriateness of quantitatively combining data from this study with the others is questionable, regardless ofthe results of heterogeneity testing In contrast to the conclusions of Nohria etal, we recently reported on the results ofa L-year randomized trial! of a video- based home telecare intervention in which we found that the ‘mean charges for heart fsilure-related readmission were 86% lower for the tlecare group and 84% lower for the telephone ‘group than the mean charges forthe patents who received ustal care, The large difference in readmission charges between the ‘usual care and intervention groups did not reach statistical sig- nificance, probably duc tothe small sample size. However, both interventions resulted in significantly fewer congestive heart failureemergency department visits and charges. Although specialist expertise may sometimes be required for ‘optimal management of heart failure, the majority of patients with heart failure are managed principally by primary care phy- sicians.? Generalists and specialists alike should strive to de- velop collaborative approaches to heart failure management. Anthony F.Jerant, MD Department of Family and Community Medicine University of California, Davis 4. Noa. A Levi Stevenson LW. Mia management of svanced est fa he Janta, 2002287:698-640 Bieler PA. Lawson FM, Te Kk, Amsttong PW. Asta review of ‘andomzed tas of dese management programs in het fue. AJ Med. soon rio37e 264 3 Weinberger Oadone £2, Henderson WG. Does ines ces primary ave reduce hospi readmission? M Eng!) Med 19964 9441- 1487 At erat AF, Azar Nesbit TS Reducing the cost of equet hospital admis Sons for congestive heat ature andomzed til of home seca nterven- {ion ed car. 200138 1234-1285, 5 taba! Center or Heath Statistics. National Ambulatory Mal Care Su oy, 1989 Summary Hyatt, Ma US Deptt Heath ana Human Series 1992 ‘area Stat 19, No. 110 In Reply: We appreciate these perspectives, As Dr Bramley sug- gests, the inereasing population of patients with truly end- stage disease mandates more thoughtful approach to their sl- fering, which can certainly be alleviated by oral opiates. Drs de Denus and Spinler note that recent information regarding ACE inhibitors docs raise considerable concer that these agents ‘may not be indicated for patients with a history of angio- edema from ACE inkibitors. Dr Jerant describes the success of 2210 JAMA stay 1, 2002 vol 287, No. 17 Repent) his program for managing heart failure. The majority of pa tients with heart failure ate indeed followed up in primary care practices. The clinicians in these settings have by far the most challenging responsibility to provide comprehensive ongoing care for heart failure while managing multiple other complex chronic illnesses Few practicing physicians now can set aside sufficient time for patient education and regular telephone calls to monitor daily fluctuations in clinical status. Whether the supervising physician is a heart failure specialist or primary are physi- ‘ian, team approach is critical to optimize outcome for these patients, Dedication and experience is required for the nurse specialist to help patients establish an optimal medical regi- ‘men, particularly forthe initiation and titration of B-blockers. ‘Our emphasis was not on the credentials of nurse-physician teams, but rather on their familiarity with these patients and the flexibility to intervene rapidly to avert decompensation, “These functions are limited for national call-in systems that are isolated from the direct providers. (Our article focused on patients with advanced heart failure in whom severe symptoms persist after the ustal therapies have been attempted. Many of the newer therapies for these pa- tientsare available only in specialized heart lure centers, where this team approach evolved through heart transplantation and

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