Extended International Normalized Ratio testing intervals for warfarin-treated patients

Essentials Warfarin typically requires International Normalized Ratio (INR) testing at least every 4 weeks. We implemented extended INR testing for stable warfarin patients in six anticoagulation clinics. Use of extended INR testing increased from 41.8% to 69.3% over the 3 year study. Use of extended INR testing appeared safe and effective.

SUMMARY

Background A previous single-center randomized trial suggested that patients with stable International Normalized Ratio (INR) values could safely receive INR testing as infrequently as every 12 weeks. Objective To test the success of implementation of an extended INR testing interval for stable warfarin patients in a practice-based, multicenter collaborative of anticoagulation clinics. Methods At six anticoagulation clinics, patients were identified as being eligible for extended INR testing on the basis of prior INR value stability and minimal warfarin dose changes between 2014 and 2016. We assessed the frequency with which anticoagulation clinic providers recommended an extended INR testing interval (> 5 weeks) to eligible patients. We also explored safety outcomes for eligible patients, including next INR values, bleeding events, and emergency department visits. Results At least one eligible period for extended INR testing was identified in 890 of 3362 (26.5%) warfarin-treated patients. Overall, the use of extended INR testing in eligible patients increased from 41.8% in the first quarter of 2014 to 69.3% in the fourth quarter of 2016. The number of subsequent out-of-range next INR values were similar between eligible patients who did and did not have an extended INR testing interval (27.3% versus 28.4%, respectively). The numbers of major bleeding events were not different between the two groups, but rates of clinically relevant non-major bleeding (0.02 per 100 patient-years versus 0.09 per 100 patient-years) and emergency department visits (0.07 per 100 patient-years versus 0.19 per 100 patient-years) were lower for eligible patients with extended INR testing intervals than for those with non-extended INR testing intervals. Conclusions Extended INR testing for stable warfarin patients can be successfully and safely implemented in diverse, practice-based anticoagulation clinic settings.

Short-Term Hemodynamic Effects of Apelin in Patients With Pulmonary Arterial Hypertension

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The effects of apelin on pulmonary hemodynamics in patients with PAH are unknown.

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Systemic infusion caused a significant reduction in pulmonary vascular resistance and increase in cardiac output without a change in heart rate or systemic vascular resistance.

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This effect was most prominent in the subgroup of patients receiving concomitant PDE5 inhibition.

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Apelin agonism is a novel potential therapeutic target for PAH.

Apelin agonism causes systemic vasodilatation and increased cardiac contractility in humans, and improves pulmonary arterial hypertension (PAH) in animal models. Here, the authors examined the short-term pulmonary hemodynamic effects of systemic apelin infusion in patients with PAH. In a double-blind randomized crossover study, 19 patients with PAH received intravenous (Pyr¹)apelin-13 and matched saline placebo during invasive right heart catheterization. (Pyr¹)apelin-13 infusion caused a reduction in pulmonary vascular resistance and increased cardiac output. This effect was accentuated in the subgroup of patients receiving concomitant phosphodiesterase type 5 inhibition. Apelin agonism is a novel potential therapeutic target for PAH. (Effects of Apelin on the Lung Circulation in Pulmonary Hypertension; NCT01457170)

Early career professionals: the mission of a task force

Early career researchers and clinicians face unique challenges in comparison with more senior colleagues, for instance connecting with expert leaders outside of their own institution to enhance their expertise. As the largest international thrombosis and hemostasis professional society, the ISTH can play a central role in supporting the development of early career professionals. The ISTH Early Career Task Force was formed to improve support for, and encourage collaboration between early career thrombosis and hemostasis researchers and clinicians. These activities include (1) maintaining an online forum for early career ISTH members to connect, promote clinical, research, funding and educational activities, and to generate a sense of community; (2) broaden ISTH's reach with early career professionals in the developing world through promotion of the Reach-the-World fellowships and translating ISTH websites into six languages; (3) encourage early career engagement with ISTH activities, such as guidelines and guidance document processing and online webinar series; and (4) establishing this early career forum series in this journal. The JTH Forum series will highlight the early career perspective on a wide range of issues relevant to this group, and all ISTH early career members are encouraged to contribute.

Reducing personal exposure to particulate air pollution improves cardiovascular health in patients with coronary heart disease

BACKGROUND

Air pollution exposure increases cardiovascular morbidity and mortality and is a major global public health concern.

OBJECTIVES

We investigated the benefits of reducing personal exposure to urban air pollution in patients with coronary heart disease.

METHODS

In an open randomized crossover trial, 98 patients with coronary heart disease walked on a predefined route in central Beijing, China, under different conditions: once while using a highly efficient face mask, and once while not using the mask. Symptoms, exercise, personal air pollution exposure, blood pressure, heart rate, and 12-lead electrocardiography were monitored throughout the 24-hr study period.

RESULTS

Ambient air pollutants were dominated by fine and ultrafine particulate matter (PM) that was present at high levels [74 μg/m³ for PM(2.5) (PM with aerodynamic diamater <2.5 µm)]. Consistent with traffic-derived sources, this PM contained organic carbon and polycyclic aromatic hydrocarbons and was highly oxidizing, generating large amounts of free radicals. The face mask was well tolerated, and its use was associated with decreased self-reported symptoms and reduced maximal ST segment depression (-142 vs. -156 μV, p = 0.046) over the 24-hr period. When the face mask was used during the prescribed walk, mean arterial pressure was lower (93 ± 10 vs. 96 ± 10 mmHg, p = 0.025) and heart rate variability increased (high-frequency power: 54 vs. 40 msec², p = 0.005; high-frequency normalized power: 23.5 vs. 20.5 msec, p = 0.001; root mean square successive differences: 16.7 vs. 14.8 msec, p = 0.007). However, mask use did not appear to influence heart rate or energy expenditure.

CONCLUSIONS

Reducing personal exposure to air pollution using a highly efficient face mask appeared to reduce symptoms and improve a range of cardiovascular health measures in patients with coronary heart disease. Such interventions to reduce personal exposure to PM air pollution have the potential to reduce the incidence of cardiovascular events in this highly susceptible population.

A major gene for resistance to white pine blister rust in Western white pine from the Western cascade range

ABSTRACT A dominant gene for resistance to white pine blister was indicated by Mendelian segregation in full-sib families of western white pine parent trees selected for phenotypic resistance in six heavily infected stands in the Western Cascades of Oregon and Washington. Seedlings were artificially inoculated three times between 1959 and 1964 and observed for development of stem infection. Segregation at this locus (Cr2) occurred in only two of the six parent populations sampled: one a natural stand, Champion Mine (CM), and the other a plantation of unknown seed origin. At CM, reduced penetrance of this gene was expressed by altered Mendelian ratios (mostly less-than-expected resistant phenotypes) in families of specific combinations of certain parents, indicating the presence of modifier genes with effects that ranged from mild to almost complete suppression of Cr2. Between 1968 and 1994, an apparent shift in virulence at CM caused all of the resistant selections to become infected and die. Recent inoculations of many of the same or related families from these parents, made from grafted ramets in a seed orchard, showed that Cr2 conditions a classical hypersensitive reaction (HR) in needle tissues, the primary infection courts. In the latter tests, seedlings were challenged with wild-type and four other sources of inoculum at and near CM that were also suspected of having wider virulence than wild type. No seedlings segregating for HR that were inoculated with wild type subsequently developed stem symptoms, but the other inocula induced both susceptible and HR needle spots on Cr2- genotypes, and many of these seedlings did develop stem infections. This implied that spore genotypes with specific virulence to Cr2 are carried in these inocula.

A comparative study of the effects of ranitidine and cimetidine on carbohydrate tolerance, growth hormone secretion and the hypothalamic-pituitary-gonadal axis in man

The effect of chronic oral administration of cimetidine (1 g per day) and ranitidine (300 mg per day) on plasma levels of prolactin (PRL), testosterone, dihydrotestosterone (DHT), luteinizing hormone (LH), follicle stimulating hormone (FSH), sex hormone binding globulin (SHBG) and human growth hormone was compared in 2 groups of male patients who presented with dyspeptic symptoms. Eight were treated with ranitidine and 9 with cimetidine for 4 weeks. The glucose and insulin response to a 100 g oral glucose load was also assessed. Cimetidine treatment resulted in a significant increase in plasma testosterone levels which was not found in the ranitidine group. No significant change occurred in PRL, LH, FSH, SHBG, DHT and growth hormone. There was no evidence of a significant alteration in carbohydrate metabolism.

Lack of effect of angiotensin on levels of cyclic AMP in isolated adrenal zona glomerulosa cells from the rat

The effects of pure [Asp1,Val5]- and [Asn1,Val5]-angiotensin II and also [des-Asp1,Ile5]-angiotensin II (angiotensin III) on cyclic AMP and steroid outputs by dispersed rat capsular cells, comprising 95% zona glomerulosa and 5% zona fasciculata cells, have been studied. The results showed that [Asp1, Val5]-and [Asn1, VAl5]-angiotensin II, at doses between 2.5 X 10(-11) and 2 X 10(-4) mol/l, which produced typical increases in steroidogenesis, failed to increase output of cyclic AMP. This lack of effect was observed whether the nucleotide was measured by radioimmunoassay or by adrenal binding protein and under the same conditions in which 8.4 mM-K+ consistently increased the output of cyclic AMP. Instead the results showed a small but significant decrease in cyclic AMP output with angiotensin II. Similar results were obtained with incubations for 60 rather than 120 min and with medium containing a concentration of 5 or 40 g bovine serum albumin/l. Although the levels of cyclic AMP were generally higher in the presence of the phosphodiesterase inhibitor, 3-isobutyl-1-methylxanthine, the same decrease relative to basal outputs was observed with angiotensin II which increased steroidogenesis. Angiotensin III also failed to increase output of cyclic AMP at doses (2.5 X 10(-9) to 2.5 X 10(-6) mol/l) which produced increases in steroid output equivalent to those with angiotensin II. These results indicate that angiotensin II and III can act through a cyclic AMP-independent mechanism.

Effect of TRH and dopamine on cyclic AMP levels in enriched mammotroph and thyrotroph cells

Populations of normal anterior pituitary cells enriched in thyrotrophs or mammotrophs prepared by velocity sedimentation were used to investigate the effect of modulators of TSH and prolactin secretion on cyclic AMP accumulation. In both thyrotroph-enriched and mammotroph-enriched fractions, IBMX increased cyclic AMP accumulation. In the presence of IBMX, TRH invoked an increase in cyclic AMP suggesting that TRH modulates cyclic AMP accumulation in both of these cell types from normal pituitary glands. In the mammotroph-rich fraction, dopamine inhibited the increase in cyclic AMP induced by TRH. In contrast however, in the thyrotroph-enriched fraction dopamine lowered neither cyclic AMP concentration nor TSH secretion. Thus the inhibiting effect of dopamine on cyclic AMP appears to be specific for prolactin-secreting cells.

Urinary cyclic AMP in the switch process from depression to mania

Various reports have suggested that the urinary excretion of adenosine cyclic 3'5’ monophosphate (cyclic AMP) is increased in mania and decreased in depression. However, our own serial studies from short-cycle bipolar manic-depressive patients showed no correlation between mood and cyclic AMP excretion (2). Jenneret al.(4) confirmed our findings, except in the case of a patient with a regular 48-hour mood cycle who did show a correlation between his mood changes and changes in cyclic AMP excretion. Paulet al.(5) also reported a general lack of correlation between these variables, but found a transient increase of urinary cyclic AMP during the rapid switch from depression to mania. We have investigated the situation in a bipolar patient who shows such a rapid switch in mood but have been unable to demonstrate any increase in cyclic AMP excretion during the switch period.