Potential impact of new oral anticoagulants on the management of atrial fibrillation-related stroke in primary care

AIM

Anticoagulant prophylaxis with vitamin K antagonists (such as warfarin) is effective in reducing the risk of stroke in patients with atrial fibrillation (AF). New oral anticoagulants have emerged as potential alternatives to traditional oral agents. The purpose of this review was to summarise the effectiveness and safety of rivaroxaban, dabigatran and apixaban in stroke prevention in patients with AF in phase III trials, evaluate their cost-effectiveness and consider the implications for primary care.

METHODOLOGY

A literature search was performed between 2007 and 2012, selecting all phase III trials (ROCKET AF, RE-LY and ARISTOTLE) of new oral anticoagulants and relevant cost-benefit studies.

RESULTS

Evidence shows that all three agents are at least as effective as warfarin in the prevention of stroke and systemic emboli, with similar safety profiles. Cost-benefit studies of rivaroxaban and dabigatran further confirm their potential use as alternatives to warfarin in clinical practice. These observations may allow stratification of the general practice AF population, to help prioritise which patients may benefit from receiving a new oral anticoagulant.

CONCLUSION

The clinical and economic benefits of the new oral anticoagulants, along with appropriate risk stratification, may enable a higher number of patients with AF to receive effective and convenient prophylaxis for stroke prevention.

How can we best detect atrial fibrillation?

Atrial fibrillation (AF) is an arrhythmia of increasing prevalence associated with a reducible risk of stroke. We conducted a systematic review to address five questions relating to how we can best detect AF: 1. Are there useful screening tests to determine who should have a 12-lead electrocardiogram (ECG)? Potential screening tests, all with acceptable sensitivity, include pulse palpation, single-lead ECG and newer technologies such as modified sphygmomanometers or a finger probe device. Pulse palpation has a high number of false positives, but is the cheapest method. 2. Is it more effective to offer 12-lead ECGs to the whole population (or specific sub-groups) or only to those who screen positive for AF? The cost-effectiveness of new devices, such as a modified blood pressure monitor, needs to be assessed. It is more cost-effective to opportunistically screen people rather than to offer a 12-lead ECG to everybody. 3. How accurate are different healthcare professionals and interpretative software at diagnosing AF on ECG? Definitive diagnosis of AF should be by 12-lead ECG, interpreted by someone with appropriate expertise. Computer software is not currently sensitive enough to be used alone to diagnose AF on ECG. Primary care practitioners may not accurately detect AF on ECG, but consistently high accuracy can be achieved by healthcare professionals with adequate training. 4. How best can we diagnose paroxysmal atrial fibrillation (PAF)? In patients in whom PAF is suspected, longer periods of monitoring will detect more cases of PAF. 5. What is the impact of the use of different ECG monitoring strategies (e.g. Holter monitoring, serial ECGs, continuous ECG) on AF detection rates post-stroke? In patients post-stroke, a single ECG will miss cases of PAF which can be detected by longer duration monitoring such as Holter monitoring, cardiac event recorders and serial ECGs. Further research into the cost-effectiveness of these methods, the duration of monitoring required and the clinical significance of the PAF detected is needed.

Serial PCR genetic load determination in the surgical management of pneumococcal intracranial sepsis

PURPOSE

Aspirated intracranial fluid, in the surgical management of intracranial sepsis, may not culture an organism due to the previous administration of antibiotics. We have sought to utilise polymerase chain reaction (PCR) to determine the cause of culture-negative sepsis and in monitoring response to therapy.

METHODS

This was a retrospective review of five cases of Streptococcus pneumoniae intracranial sepsis. Samples were analysed using real-time quantitative PCR targeting the pneumococcal lytA gene and the number of genome copies per microlitre of sample determined.

RESULTS

Streptococcus pneumoniae sepsis was diagnosed by PCR in five culture-negative cases comprising: ventriculitis (×3), subdural empyema and meningitis. Serial serum inflammatory markers (CRP and WBC) and number of genome copies were graphically plotted over the duration of inpatient stay for cases requiring surgical drainage of recurrent collections or external ventricular drainage. A correlation was demonstrated between change in bacterial genomic load and serum inflammatory markers, reflecting similar changes in clinical state.

CONCLUSIONS

This is the first report of the use of serial quantitative PCR in monitoring the course of intracranial sepsis secondary to S. pneumoniae. Further work is required to determine the precise relationship between serum inflammatory markers, clinical state and bacterial load: do changes in one precede the other? Furthermore, a threshold value for number of genome copies in cerebrospinal fluid/aspirate samples has yet to be defined.

Transgrediens pachyonychia congenita (PC): case series of a nonclassical PC presentation

BACKGROUND

Pachyonychia congenita (PC) is a rare keratin disorder that typically presents with nail dystrophy and focal plantar keratoderma. We present seven cases of PC with transgrediens involvement of the dorsal feet.

OBJECTIVES

To document the extension of their disease to the dorsum of the feet in patients with mutation-confirmed PC, to report the natural history of PC with such transgrediens involvement, to generate hypotheses regarding aetiology, and to suggest prevention and treatment modalities.

METHODS

Genetically confirmed cases of PC with transgrediens foot involvement were verified through the International Pachyonychia Congenita Research Registry (IPCRR) and characterized via telephone survey and photography.

RESULTS

Seven patients with PC in the IPCRR were confirmed to have transgrediens lesions on the dorsal feet (six KRT6A mutations; one KRT16 mutation). Six cases had pre-existing nontransgrediens keratoderma and all cases reported standing, wearing shoes, foot moisture, and/or infection as exacerbating or predisposing factors. Improvement, reported in six cases, was attributed to use of antibiotics or gentian violet, or improved footwear.

CONCLUSIONS

Transgrediens involvement of the dorsal feet is a rare manifestation of mutation-confirmed PC and may be more common in patients who carry a KRT6A mutation. Trauma, friction, infection and wound healing may exacerbate or predispose toward transgrediens lesions. It remains to be proven whether transgrediens-associated infection is causal or represents a primary or secondary process. Patients with PC who develop transgrediens lesions may benefit from fungal and bacterial cultures, followed by appropriate antimicrobial treatments. Efforts to decrease skin friction and moisture may also improve and/or prevent transgrediens spread.

Septicaemia due to enteric organisms is a later event in surgical infants requiring parenteral nutrition

INTRODUCTION

The purpose of this study was to determine whether, in surgical infants requiring parenteral nutrition (PN), septicaemia due to enterococci or Gram-negative bacilli occurs later than septicaemia due to coagulase-negative staphylococci (CNS).

PATIENTS/MATERIAL AND METHODS

We retrospectively studied 112 consecutive surgical infants (corrected gestational age up to 3 months) receiving PN for at least 5 days for congenital or acquired intestinal anomalies over a 2-year period (July 2007-June 2009). Data collected included diagnosis, duration of PN, episodes of septicaemia (defined as growth of bacteria from blood culture), and organisms cultured. We compared the time to first occurrence of septicaemia due to CNS with the times to first occurrence of septicaemia due to enterococci, Gram-negative bacilli, or other micro-organisms, using Kruskal-Wallis nonparametric ANOVA test and Dunn's multiple comparisons test. Data are given as median (range).

RESULTS

31 patients (28%) had a total of 65 episodes of septicaemia. Septicaemia due to CNS was most common, occurring in 22% of patients, after 17 days (1-239) of PN. Septicaemia due to enteric organisms was less common and occurred significantly later, at 59 (24-103) days for enterococci (p<0.01), and at 55 (30-106) days for Gram-negative bacilli (p<0.05).

CONCLUSIONS

Septicaemia due to enterococci or Gram-negative bacilli occurs later in the course of PN than septicaemia due to CNS, in surgical infants. This suggests that these infants become more vulnerable to the translocation of enteric micro-organisms after a longer period of parenteral nutrition.

188 HUMAN FOLLICULAR FLUID IN EQUINE IN VITRO MATURATION MEDIUM SUPPORTS IN VITRO MATURATION AND VIABLE INTRACYTOPLASMIC SPERM INJECTION-BLASTOCYST PREGNANCIES

The aim of this study was 2-fold: (1) To determine if altrenogest-treated mares will yield higher numbers of quality in vitro-matured (IVM) oocytes than early pregnant mares and cycling/control mares and (2) if the addition of human follicular fluid (HFF) to IVM medium can support IVM and viable pregnancies from in vitro-produced blastocysts. In this study, 18 mares were assigned to 3 equally sized treatment groups and each mare was subjected to follicle aspiration every 10 to 11 days without monitoring follicular growth. The 3 treatment groups were altrenogest-treated mares (0.044 mg kg–1 of PO daily), early pregnant mares (30–110 days) and control/cycling mares. Using transvaginal ultrasound guidance, all visible follicles were aspirated. Altrenogest-treated mares each yielded more follicles (8.75) per aspiration session when compared with the control mare group (5.75) and the pregnant mare group (3.72), but there was no difference in oocyte recovery rates among the groups (Table 1). A limited number of these oocytes were subjected to in vitro maturation. After heated (38.5°C) transport of oocytes to an off-site laboratory, the oocytes were placed in maturation medium containing 10% HFF obtained from preovulatory follicles after ovulation induction, 20% serum substitute supplement and no hormones for 36 h. This approach yielded a maturation rate of 61.8, 68.8 and 82.0% for the altrenogest, pregnant and control treatment groups, respectively (not significant). Mature oocytes (n = 65) were injected with frozen-thawed sperm using a standard intracytoplasmic sperm injection (ICSI) technique. Four expanding blastocysts (Table 1) were selectively transported back to the embryo transfer facility and transcervically transferred into recipient mares on Day 6 post-ICSI. These 4 transfers resulted in 2 viable, normally progressing pregnancies, ongoing beyond 60 days of gestation. Both pregnancies resulted from the altrenogest-treated aspiration group. In this study we concluded that (1) altrenogest-treated mares provide more follicles and may be a better source of viable immature oocytes for the production of ICSI embryos and foals, but their overall advantage is unclear; (2) addition of HFF to IVM media, in the absence of added gonadotropins, can support oocyte maturation, blastocyst production and viable pregnancies; (3) an aspiration schedule of every 10 to 11 days without ultrasonic monitoring can yield viable immature oocytes, capable of producing ICSI blastocysts, resulting in viable pregnancies. Table 1.Altrenogest-treated mares compared to early pregnant mares and control mares

Trends and transient change in end-digit preference in blood pressure recording: studies of sequential and longitudinal collected primary care data

BACKGROUND

End-digit preference (EDP) is a known cause of inaccurate BP recording. Distortion has been reported around pay-for-performance (P4P) indicators.

METHODS

We studied sequential datasets (n = 148,000 to n = 900,000) and performed a longitudinal analysis of CONDUIT data (n = 250,000) over a 10-year period. We examined general trends in EDP and investigated the impact of diabetes and chronic kidney disease (CKD) P4P targets.

RESULTS

EDP reduces over time in both datasets; the percentage of patients with a zero EDP declined from 70% to 27% and 68% to 26% for SBP and DBP respectively. There is more zero EDP at the extremes of BP, but in people with chronic disease, the use of zero EDP was mainly seen at higher BP levels. P4P targets are associated with increased preference for the even end-digit just below target: in diabetes odds ratio (OR) is 1.47 (p = 0.003) for SBP, 1.19 (p = 0.09) for DBP and in CKD OR 1.65 (p < 0.001) for SBP and 1.48 (p = 0.0001) for DBP. Trends observed in pilot data were validated with a longitudinal set.

CONCLUSIONS

The decline in EDP is levelling off and P4P targets are associated with sub-target-EDP. Primary care should automate BP measurement and recording.

Giant cell tumor of the infratemporal fossa

Giant cell tumors are an uncommon neoplasm; most are found in the long bones, formed by endochondral ossification. This article presents a case of giant cell tumor of the infratemporal fossa, which by radiographic and clinical examination appears to have originated in the squamous portion of the temporal bone.

Service provision and training for endoscopic ultrasound in the UK

Endoscopic ultrasound (EUS) is a standard procedure that plays an important role in the management of both malignant and benign disease. The development of EUS services in the UK has been haphazard and training inconsistent. The British Society of Gastroenterology has charged a working group with the task of laying down a national framework for how such services might be commissioned, structured and regulated; with particular attention to defining how endoscopist skills might be acquired, assessed and maintained. This report lays out a map for this process and its future revision.

Intramuscular immunization of mice with live influenza virus is more immunogenic and offers greater protection than immunization with inactivated virus

BACKGROUND

Influenza virus continues to cause significant hospitalization rates in infants and young children. A 2-dose regime of trivalent inactivated vaccine is required to generate protective levels of hemagglutination inhibiting (HAI) antibodies. A vaccine preparation with enhanced immunogenicity is therefore desirable.

METHODS

Mice were inoculated intramuscularly (IM) with live and inactivated preparations of A/Wisconsin/67/2005 (H3N2). Serum cytokine levels, hemagglutinin (HA)-specific antibody responses and nucleoprotein (NP)-specific CD8+ T cell responses were compared between vaccinated groups, as well as to responses measured after intranasal infection. The protective efficacy of each vaccine type was compared by measuring virus titers in the lungs and weight loss of mice challenged intranasally with a heterosubtypic virus, A/PR/8/34 (H1N1).

RESULTS

Intramuscular administration of live virus resulted in greater amounts of IFN-α, IL-12 and IFN-γ, HA-specific antibodies, and virus-specific CD8+ T cells, than IM immunization with inactivated virus. These increases corresponded with the live virus vaccinated group having significantly less weight loss and less virus in the lungs on day 7 following challenge with a sublethal dose of a heterosubtypic virus.

CONCLUSIONS

Inflammatory cytokines, antibody titers to HA and CD8+ T cell responses were greater to live than inactivated virus delivered IM. These increased responses correlated with greater protection against heterosubtypic virus challenge, suggesting that intramuscular immunization with live influenza virus may be a practical means to increase vaccine immunogenicity and to broaden protection in pediatric populations.

Demographic profile and utilization statistics of a Canadian inpatient palliative care unit within a tertiary care setting

Background

Canadian data describing inpatient palliative care unit (pcu) utilization are scarce. In the present study, we performed a quality assessment of a 24-bed short-term pcu with a 3-months-or-less life expectancy policy in a tertiary care setting.

Methods

Using a retrospective chart review, we explored wait time (wt) for admission (May 2005 to April 2006), length of stay [los (February 2005 to January 2006)], and patient demographics.

Results

The wt data showed 508 referrals, with 242 resulting in admissions (92% malignant diagnoses) and 266 not (82% malignant). The most common malignancies in both groups were gastrointestinal, lung, and genitourinary. Median wt for admitted patients was 6 days, varying with referral source, such as the same hospital, home, or another hospital (6, 4, and 8.5 days respectively). Most admissions (93%) occurred in 21 or fewer days. Patient death (52%), admission to another pcu (25%), and declined offer (10%) were common reasons for no admission. Median los for 219 admitted patients was 19 days (range: 0–249 days). Most patients (94%) died in the pcu; a minority were discharged.

Conclusions

Many patients requiring pcu services are admitted within a few days of referral, especially patients with the least available support: those at home. However, half of the non-admitted patients die while waiting—a potential area for improvement. The los for admitted patients complied with the 3-month “expected lifespan” pcu policy. Results are significant, because ensuring quality of life for palliative care patients includes timely pcu access and sufficient los to address end-of-life needs.