Cochrane corner: self-monitoring and self-management of oral anticoagulation

Catechol-chitosan/carboxymethylated cotton-based Janus hemostatic patch for rapid hemostasis in coagulopathy

Uncontrolled bleeding is the leading cause of death, and the death risk of bleeding from coagulopathy is even higher. By infusing the relevant coagulation factors, bleeding in patients with coagulopathy can be clinically treated. However, there are not many emergency hemostatic products accessible for coagulopathy patients. In response, a Janus hemostatic patch (PCMC/CCS) with a two-layer structure of partly carboxymethylated cotton (PCMC) and catechol-grafted chitosan (CCS) was developed. Ultra-high blood absorption (4000 %) and excellent tissue adhesion (60 kPa) were both displayed by PCMC/CCS. The proteomic analysis revealed that PCMC/CCS has significantly contributed to the creative generation of FV, FIX, and FX, as well as to the substantial enrichment of FVII and FXIII, re-paving the initially blocked coagulation pathway of coagulopathy to promote hemostasis. The in vivo bleeding model of coagulopathy demonstrated that PCMC/CCS was substantially more effective than gauze and commercial gelatin sponge at achieving hemostasis in just 1 min. The study provides one of the first investigations on procoagulant mechanisms in anticoagulant blood conditions. Rapid hemostasis in coagulopathy will be significantly affected by the results of this experiment.

A descriptive cross-sectional study of self-management in patients with nonvalvular atrial fibrillation

Self-management of non-valvular atrial fibrillation (NVAF) is characterized by complexity and diversity of content. Inadequate self-management exposes patients to the risk for complications such as stroke and bleeding. To assess the status and predictors of self-management in NVAF patients, a descriptive cross-sectional study was conducted. The self-management scales for atrial fibrillation were used to assess the status of self-management of patients who received Warfarin, NOAC, Aspirin, or No anticoagulant therapy. The general situation questionnaire was used to collect socio-demographic and clinical data from patients. A total of 555 participants completed the survey, with self-management score of 71.21 ± 12.33, 69.59 ± 13.37, 69.03 ± 12.20 and 66.12 ± 11.36 in Warfarin group, NOAC group, Aspirin group and No anticoagulant group, respectively. In Warfarin group lower educational status was associated with poor self-management; in Aspirin group, comorbidities and age < 65 years (P = .001) were associated with poor self-management; in No anticoagulant group, age < 65 years, single, poor sleep quality, and permanent AF were associated with poor self-management. Self-management was inadequate in patients with NVAF. Poor self-management might be related with the occurrence of cerebral embolism. For NVAF patients receiving anti-thrombotic therapy, relatively young age, comorbidities, and age can have a substantial impact on self-management performance; while age, type of AF, quality of sleep, married status are associated with self-management in patients with no anticoagulants.

Online KidClot education for patients and families initiating warfarin therapy: The eKITE study

Anticoagulation with Vitamin K antagonists (VKA) has always posed challenges in terms of monitoring requirements. These challenges were further exacerbated in the setting of the COVID-19 pandemic, with limited access to and/or avoidance of laboratory testing. The importance of utilizing point of care (POC) health technology for individualized patient management is salient. The foundation of effective home INR monitoring is establishing patient knowledge about their therapy and INR testing proficiency. The eKITE series was developed to support patients in establishing foundational knowledge required for VKA (warfarin) management and INR monitoring. The primary objectives were to evaluate eKITE, a patient-oriented innovative online education program for warfarin therapy, participant learning stress, and patient preference for online learning. This multi-center prospective study provided patients access to warfarin online education. Participants were required to complete written quizzes assessing warfarin knowledge of key concepts proficiency and identifying knowledge deficits. Patient preference, evaluating calm (lack of anxiety) while learning, and an INR on a home meter was completed. Participants performed INR tests at home and reported INRs by telephone. The analysis included 144 children and caregivers enrolled at five US and CDN sites. Most indications for anticoagulation were cardiac (congenital or acquired heart disease) with varied INR target ranges. Mean knowledge scores for warfarin and INR self-testing modules were 97%, with low anxiety with TTR of 84%. Patient preferred online learning. eKITE is an effective teaching modality for warfarin/home INR monitoring with safe INR testing and warfarin management that is appropriate for pediatrics and adults alike. PROLOGUE: The whir in the hallways is deafening. Lights bright, alarms are ringing in a chorus of unsynchronized beeps and screeches. It has been more than a week since I have slept. Snuggled beside me is my precious child, whining and equally irritated with the asynchronous symphony, further compounded by anxiety, procedures, and pain. The sun has broken. The staff smiles are welcoming and incessant, as one after one, they approach hurried, urgent, assiduous, their need to coach me for our upcoming departure to the warmth of home. Each provides essential information that I will require to keep my child, my treasure, safe and healthy. Yet, my eyes are heavy, blurred, and my brain foggy, trapped in a dark heavy cloud. How am I to follow? Comprehend? and retain anything? As they instruct, my precious child yearns for loving arms, compassion and love, whining, crying in disquiet. Overwhelmed does not adequately describe my ineffable exhaustion. Amidst this, how am I to learn about warfarin? Such a challenging medication, with so much to know. Concentrate, I tell myself, focus; now is my only opportunity to learn. I must be alert. It seems to be nonsensical.

Point-of-care testing technologies for the home in chronic kidney disease: a narrative review

Point-of-care testing (POCT) performed by the patient at home, paired with eHealth technologies, offers a wealth of opportunities to develop individualized, empowering clinical pathways. The non-dialysis-dependent chronic kidney disease (CKD) patient who is at risk of or may already be suffering from a number of the associated complications of CKD represents an ideal patient group for the development of such initiatives. The current coronavirus disease 2019 pandemic and drive towards shielding vulnerable individuals have further highlighted the need for home testing pathways. In this narrative review we outline the evidence supporting remote patient management and the various technologies in use in the POCT setting. We then review the devices currently available for use in the home by patients in five key areas of renal medicine: anaemia, biochemical, blood pressure (BP), anticoagulation and diabetes monitoring. Currently there are few devices and little evidence to support the use of home POCT in CKD. While home testing in BP, anticoagulation and diabetes monitoring is relatively well developed, the fields of anaemia and biochemical POCT are still in their infancy. However, patients' attitudes towards eHealth and home POCT are consistently positive and physicians also find this care highly acceptable. The regulatory and translational challenges involved in the development of new home-based care pathways are significant. Pragmatic and adaptable trials of a hybrid effectiveness-implementation design, as well as continued technological POCT device advancement, are required to deliver these innovative new pathways that our patients desire and deserve.

Measuring what matters to the patient: health related quality of life after aortic valve and thoracic aortic surgery

With improved outcomes following cardiac surgery, health related quality of life (HRQoL) gains increasing importance for the better judgement of choosing the preferred treatment strategy in the individual patient. The physician perception of patient preferences can differ considerably from actual patient preferences, underlining the importance of gathering evidence of actual patient preferences before and quality of life after cardiac surgery. The objective of the current review is to provide an overview of current insights into the quality of life measurements after aortic valve and thoracic aortic surgery and to provide starting points for the application of HRQoL measurements toward the future. The amount and level of evidence on HRQoL outcomes after aortic valve and thoracic aortic surgery seems to be insufficient. Little has been investigated about the natural course of HRQoL after cardiac surgery, HRQoL outcomes between different surgical strategies, HRQoL outcomes between surgical patients and the general population, the different factors influencing HRQoL after cardiac surgery, and the effect of HRQoL on healthcare costs. More prospective studies should be performed, taking into account the knowledge gaps that need to be filled. Computerized adaptive testing methods through open source programs can be implemented to keep the burden to the patient as low as possible and catalyze the use of these tools. Our cardiovascular surgery community has the responsibility to deliberate how it can proceed to effectively fill in these knowledge gaps, and use this newfound knowledge to improve shared treatment decision making, patient outcomes, and ultimately optimize health care efficiency.

Effectiveness and safety of self-managed oral anticoagulant therapy compared with direct oral anticoagulants in patients with atrial fibrillation

We compared the effectiveness and safety of direct oral anticoagulants (DOAC) vs patient self-managed warfarin therapy (PSM) in patients with atrial fibrillation. We linked prospectively registered data from university hospital clinics to nationwide Danish health registries. Primary effectiveness and safety outcomes were ischaemic stroke (incl. systemic embolism) and major bleeding. All-cause mortality and all-cause stroke were secondary outcomes. An inverse probability of treatment propensity-weighted approach was applied to adjust for potential confounding. The study cohorts included 534 patients treated with PSM and 2,671 patients treated with DOAC. Weighted rates of ischaemic stroke were 0.46 and 1.30 percent per year with PSM vs DOAC, hazard ratio (HR) 0.27 (95% confidence interval 0.11-0.68) with 2.5 years follow-up. Rates of major bleeding were 2.32 and 2.13 percent per year (HR 1.06 [0.69-1.63]). All-cause mortality was not statistically different (HR 0.67 [0.39-1.17]), whereas the incidence of all-cause stroke was significantly lower among patients treated with PSM with rates of 0.61 vs 1.45 percent per year (HR 0.36 [0.16-0.78]). In patients with atrial fibrillation, self-managed oral anticoagulant treatment was associated with a significantly lower risk of all-cause and ischaemic stroke compared to treatment with DOAC, whereas no significant differences were observed for major bleeding and mortality.