Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors Use among Heart Failure Patients and the Role of Pharmacists in Early Initiation of Therapy

Heart failure (HF) is a growing major public health and economic concern in the United States and worldwide. Heart failure mortality rates can be as high as 75% despite advances in therapies. HF is expected to be the fastest growing among all cardiovascular diseases, with HF-associated direct medical costs projected to nearly double over the next 10 years. Hospital admissions, re-admission, and medical cost are a huge burden to the healthcare system, and this is estimated to have increased gradually over the past decades despite the available advances in HF treatment and prevention. Many heart failure therapies have shown improvement in terms of mortality, morbidity, and symptomatic management. Guideline-directed medical therapy (GDMT) for heart failure has proven its ability to reduce morbidity and mortality by 66%. GDMT is recommended to be used among all HF patients when appropriate. In recent years, two new drug classes, angiotensin receptor-neprilysin inhibitor (ARNi) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors, were approved by the United States Food and Drug Administration (US FDA) for the management of heart failure. The exact mechanism by which the SGLT-2 inhibitors attenuate the inflammatory process remains unclear. Several mechanisms have been suggested related to the cardiovascular benefit of SGLT-2 inhibitors, including a reduction in inflammation, improvement in natriuresis/diuresis, and promotion of the use of ketones as a secondary energy source. Clinical data showed that SGLT-2 inhibitors have morbidity and mortality benefits within 30 days of initiation. Studies have proven that clinical pharmacists practicing in HF inpatient and outpatient settings resulted in a reduction of HF hospitalization and an increase in the uptake of GDMT by initiating or up-titrating GDMT agents as well as providing patient education.

Hypersensitivity reactions to parenteral vitamin K

Cutaneous hypersensitivity reactions to vitamin K are rare. They occur almost exclusively with fat-soluble vitamin K (K1). The lesion is most commonly a pruritic, indurated plaque at the site where the vitamin was injected. Most plaques resolve within 4 to 8 week without sequelae, but some progress to produce scar-like changes that may last for years.

Proliferating trichilemmal cyst. Report of four cases, two with nondiploid DNA content and increased proliferation index

Proliferating trichilemmal cyst (PTC) is an uncommon tumor that usually arises on the scalp of elderly women. Its biologic nature is that of a benign lesion with occasional local recurrences. PTC can be confused both grossly and microscopically with squamous cell carcinoma and malignant PTC. Distinction between these lesions has historically been made on a histologic basis. We present four cases of PTC. Histologically, the lesions consisted of lobules of basaloid cells admixed with larger pale-staining cells with abrupt trichilemmal type of keratinization and peripheral palisading embedded in a fibrous stroma. Flow cytometry performed on nuclear extracts of the lesions revealed two of the four lesions to have nondiploid DNA content. Proliferation index, measured by immunohistochemical staining with Ki-67 monoclonal antibody along with mitotic rate count, was higher in the two nondiploid lesions as compared with their diploid counterparts. The results raise the question of the significance of aneuploidy and increased proliferation indices in otherwise benign PTC.

Photoaging. Cosmetic effects of sun damage

Given the many ways our culture promotes deeply tanned skin as a symbol of beauty, health, and even happiness, physicians face an uphill battle in promoting the healthy aspects of a pale complexion. Not only can excessive solar exposure accelerate and intensify aging in skin, it can also lead to serious health risks. Drs Browder and Beers tell why photoaging happens and how to prevent it.

Unilateral linear lichenoid eruption after bone marrow transplantation: an unmasking of tolerance to an abnormal keratinocyte clone?

Chronic cutaneous graft-versus-host disease may appear clinically as a lichenoid eruption. We describe a 26-year-old man who developed a unilateral linear lichenoid eruption 7 months after allogeneic bone marrow transplantation. We believe this represents an unusual form of localized, chronic graft-versus-host disease. The possible relationship to viral infection or cellular mosaicism and the clinical, histologic, and immunologic similarities to idiopathic lichen planus are discussed.

Porokeratosis palmaris et plantaris disseminata. Report of a case with abnormal DNA ploidy in lesional epidermis

BACKGROUND

Porokeratosis is believed to be a premalignant condition of the skin. Recent flow cytometric studies showing DNA aneuploidy in the epidermis of some types of porokeratosis support this conclusion. We describe a patient with porokeratosis palmaris et plantaris disseminata in whom abnormal DNA ploidy was found in lesional epidermis with the use of flow cytometry.

OBSERVATIONS

DNA flow cytometry of lesional epidermis from the back showed two populations of cells, one with diploid and the other with aneuploid DNA content and DNA index of 1.1 (hyperdiploid). The coefficient of variation of the diploid and aneuploid peaks was 2.1% and 4.1%, respectively.

CONCLUSIONS

Porokeratosis palmaris et plantaris disseminata, like other forms of porokeratosis, exhibits abnormal DNA ploidy in lesional epidermis. This finding underscores the premalignant nature of this and other forms of porokeratosis.