[Fake paper factories: root cause solutions are needed.]

The pressure to publish academic papers for career advancement and technological innovations have fostered the growth of a new phenomenon, the serial fabrication of articles to be submitted to scientific journals. Papers with fake content are produced by specialised publishing agencies. Journal editors and publishers increased vigilance and control, tightening the peer review process and using anti-plagiarism software. But, being a systemic issue, it is not easy to find the solution and action must be taken on its causes: greater awareness of research ethics is needed, specific training for young doctors and - in the long run - an appropriate use of artificial intelligence, which should become a tool for protecting the integrity of knowledge.

[The EASY-NET research programme: background, structure, and methodology]

This is the first contribution of a series of interventions describing the EASY-NET research program (Bando Ricerca Finalizzata 2016, funds 2014-2015; NET-2016-02364191). Here, the objective is to illustrate the background and the research question, the structure and organization, the methodologies and the expected results of the programme. The main theme is audit&feedback (A&F), a proven and widespread technique for improving the quality of health care. EASY-NET, funded by the Italian Ministry of Health and by the governments of the participating Italian Regions, starts its research activities in 2019 with the aim of evaluating the effectiveness of A&F in improving care for different clinical conditions in various organizational and legislative contexts. The research network involves seven Italian Regions, each conducting specific research activities described by as many work packages (WP): Lazio (the leading Region, coordinator of the research activities), Friuli Venezia Giulia, Piedmont, Lombardy, Emilia-Romagna, Calabria, and Sicily. The involved clinical areas include the management of chronic diseases, emergency care for acute conditions, surgery in the oncological area, the treatment of heart disease, obstetrics, and the use of caesarean section and post-acute rehabilitation. The involved settings concern the community, the hospital, the emergency room, and the rehabilitation facilities. Different experimental or quasi-experimental study designs are applied in each WP to achieve specific objectives of the specific clinical and organizational context. In all WPs, the process and outcome indicators are calculated on the basis of the Health Information Systems (HIS) and, in some cases, they are integrated with measures obtained from ad hoc data collections. The programme aims to contribute to the scientific evidence on A&F also exploring the obstacles and favourable factors for its effectiveness and to promote its implementation in the health service, with the ultimate aim of improving the access to healthcare and the health outcomes for citizens.

[Who is the author of a scientific article?]

Authorship is increasingly discussed in international journals: in fact, the authorship and position of authors influence professional careers, the acquisition of funding, and individual and institutional reputation. International associations of editors of academic journals call for vigilance in cases of misconduct: ghostwriting and guest or gift authorship are frequent and penalise especially younger researchers and women. However, authorship is a concept in the making, strongly influenced not only by the social and ethical context, but also by technology. Today, artificial intelligence is an important aid for the editorial boards of academic journals. But it is likely to become a support for authors in the future as well, given the success of automatic writing software.

Italian health professionals on the mandatory COVID-19 vaccine: An online cross-sectional survey

Italy was the first country in Europe to make vaccination against COVID-19 mandatory for healthcare professionals by imposing restrictions in cases of non-compliance. This study investigates the opinions of the Italian healthcare professionals' categories affected by the regulation. We performed a qualitative online survey: the questionnaire comprised both close- and open-ended questions. The final dataset included n = 4,677 valid responses. Responses to closed-ended questions were analyzed with descriptive statistics. The framework method was applied for analyzing the open-ended questions. The sample spanned all health professions subject to compulsory vaccination, with a prevalence of physicians (43.8%) and nurses (26.3%). The vaccine adhesion before the introduction of the obligation was substantial. 10.4% declared not to have adhered to the vaccination proposal. Thirty-five percent of HPs who opted not to get vaccinated said they experienced consequences related to their choice. The trust in the vaccine seems slightly cracked, demonstrating overall vaccine confidence among professionals. Nonetheless, our results show that whether (or not) professionals adhere to vaccination is not a reliable indicator of consent to how it was achieved. There are criticisms about the lawfulness of the obligation. The data show a great variety of participants interpreting their roles concerning public and individual ethics. The scientific evidence motivates ethics-related decisions-the epidemic of confusing and incorrect information affected professionals. The Law triggered an increased disaffection with the health system and conflicts between professionals. Dealing with the working climate should be a commitment to assume soon.

[Presumed guilty. Falsification and fabrication of data in scientific publications.]

The falsification of results and the fabrication of scientific research data are on the rise. Famous researchers see their articles pulled from leading journals. Often, however, this editorial malpractice does not harm the reputation of the authors, who continue to progress in their careers. The solution cannot come from a greater awareness of researchers, sponsors, regulatory agencies or research institutions: the incentives for malpractice are too strong. We need a new international governance of research and communication.

[The Liberati's principles ten years later.]

Ten years after the death of Alessandro Liberati, the authors wonder how much the principles that guided the action of the founder of the Italian Cochrane Centre are still relevant. The guiding star of Liberati's professional life was the fight for useful research aimed at solving problems relevant to patients and their families. Consistently with the work of other researchers such as Sir Iain Chalmers and Paul Glasziou - they have recently offered important contribution on these issues - Alessandro Liberati worked hard to guarantee open, accessible, and transparent research to citizens, health decision makers and health professionals. Unfortunately, his final call to design a new research governance remained unanswered. Research is still too focused on individual therapeutic interventions rather than on overall care strategies. Studies are still too often unpublished or only partially published. Research is still influenced by conflicts of interest and peer review is often biased. Much work remains to be done, to ensure that publicly funded research is guided by the real needs of citizens and patients.

[Pandemic emergency as a stress test for the health system.]

One year after the beginning of the health and social emergency, the health system shows its strengths and weaknesses. Among these, inadequacy of facilities, deficiencies of continuity between hospital and territory, inconsistent information and lack of bidirectional communication between institutions and citizens, uncertainties of data about therapies and the emphasis given to the role of opinion leaders. To get out of the pandemic, a change of perspective is needed: governments must not just support industrial investments but must they must encourage better and community-useful research and communication.

[Ethics in health communication.]

Health communication must be based on open and multi-dimensional dialogue involving all stakeholders: public and private institutions, health professionals, industries, associations and, above all, citizens. Currently, communication suffers many problems related to bad research (unethical research, falsification of data, conflict of interest, incomplete reporting, spin and plagiarism) and to the limits of an academic system that does rewards quantity more than quality. A turnaround is needed, based on five major changes: establishing rules that can actually be followed; improve the quality of scientific information; accept and encourage open confrontation; allow citizens to be able to express and assert their needs; transform uncertainty from limit to value. The "Liberati's principles" must be reaffirmed: an honest communication must make the results of the research accessible to those who have to make decisions that affect their health; researchers must engage in studies that promise benefits to citizens and are not just useful to one's career or industry; before opening up new research fronts it is necessary to exhaust the potential of research already started; the definition of research priorities must be a transparent and shared process; the best evidence is the most relevant for citizens and patients. These principles and all ethical issues related should be part of educational programs for all health operators and researchers.

[Professional societies and conflict of interests governance.]

The complexity of health systems often implies a condition of conflict of interests for many of the players involved: health professionals, managers of the NHS, pharmaceutical, medical devices or food industries, publishers and communication agencies, conference event organizers. Conflict of interests is a condition of risk, not a sentence of guilt: for this reason, conflict of interests should be managed through information and training of health personnel. Scientific societies play an important role being active in updating their members (conferences, meetings, e-learning and residential training courses) and influencing healthcare with the production of clinical practice guidelines. Professional associations must be active to foster the integrity of their members and to minimize the risk of conflict of interests, also to avoid wasting resources, making the health system fairer and more sustainable.

Information needs on precision medicine: a survey of Italian health care professionals

BACKGROUND

Despite advances in technology development for precision medicine, obstacles remain as barriers to progress and change. In this context simple questions arise: what is the level of understanding of precision medicine among healthcare professionals? We tried to address this question with a survey whose objective was to explore the perception and understanding of precision medicine.

METHODS

A questionnaire was administered to a sample made of oncologists, clinical and hospital pharmacists, pharmacologists and infectiologists in the context of five different Italian national congresses. Participation in the survey was voluntary and anonymous.

RESULTS

The questionnaire was filled-in by a total number of 1113 professionals out of 3670 registered participants in the congresses. About half of respondents stated they were not sufficiently informed about precision medicine, and infectiologists were the ones who felt less informed. Most respondents agreed with the basic principles and definitions of precision medicine and believed this new approach is going to require deep changes in healthcare.

CONCLUSIONS

Our findings show that healthcare professionals have partial knowledge on this topic and that there is a significant association between respondents' knowledge and their clinical specialty. However, despite some misconceptions about precision medicine, a genuine interest and familiarity with its basic principles seems to emerge.

[Real-world evidence.]

Real-world evidence is among the most frequently discussed issues at professional medical conferences and meetings. It refers to data and information derived from sources such as electronic health records, disease or product registries, and observational research. Looking for an accelerated approval of new pharmaceutical products and devices, real-world evidence is considered a useful tool to confirm data collected for regulatory purposes. Anyway, randomised controlled trials still remain the gold standard of clinical research, in order to minimize bias and to evaluate the effectiveness of a clinical intervention. A pragmatic approach and quasi-randomised trials to shorten length and costs of the studies can be considered. The problem lies with the quality of data rather than with the context in which evidence is gathered.

Data Sharing, Clinical Trials, and Biomarkers in Precision Oncology: Challenges, Opportunities, and Programs at the Department of Veterans Affairs

Cancer genomic research reveals that a similar cancer clinical phenotype (e.g., non-small cell lung cancer) can arise from various mutations in tumor DNA. Thus, organ of origin is not a definitive classification. Further, targeted therapy for cancer patients (precision oncology) capitalizes on knowledge of individual patient mutational status to deliver treatment directed against the protein products of these mutations with the goal of reducing toxicity and enhancing efficacy relative to traditional nontargeted chemotherapy.

[Plagiarism. A fools' errand.]

An old Italian proverb states that lies have short legs. In other words, in the end you get found out. This is exactly what happened to an Italian researcher who acted as a referee for a manuscript submitted in 2015 to Annals of Internal Medicine. After a negative report (which presumably led to the rejection of the submission) he submitted a manuscript which was essentially the same. But he and his accomplices got found out and paraded in front of the world in an earth-shatteringly polite "Dear Plagiarist" letter by the first robbed author: Dr Michael Dansinger. Dr Dansiger's letter is a model of polite logic and an ethical masterpiece, the fake article got retracted and the thief's institution contacted. No reply so far, a depressingly familiar theme in contemporary research. We wonder why we carry on with a system which is completely broken. Commercial interests, reporting bias, secrecy, ethically dubious studies and inertia are the ingredients of contemporary research and publication practices. Editorial peer review, a scholarly practice originating in a more genteel era, is clearly unable to do much other than lend a very thin veneer of credibility to this pandemic of junk which is threatening healthcare budgets and the ethics of the next generation of researchers. We need a complete reform of the system which could give back some credibility to the "e" of evidence-based medicine. Complete lawful transparency, public reimbursement of interventions only on the basis of independently generated evidence and research ethics as a part of an international curriculum for budding researchers are urgently needed. These should be linked to publishers' complete disclosure of their sources of income and custodial sentences for those who abuse positions of trust. Meanwhile, stay away from anything implausible and non-replicable (as they probably are).

[Biomedical research from philanthropy to scarcity.]

Some huge information technology companies have increased investment in biomedical research: recently Google, Microsoft, and Facebook. The latter presented the ambitious Zuckerberg-Chan Initiative involving three major Californian universities: UC San Francisco, Berkeley and Stanford. These important private investments arouse reflections. First, investing in scientific research improves the corporate image of the most generous companies and it is a great marketing strategy. Second, the availability of private funds is surely useful, especially if these funds are directed to relevant projects, and produce studies conducted and disseminated in a transparent way. Third, private funding should not replace public ones, representing an integration that will not likely affect the determination of the research agenda, which should remain the prerogative of public institutions. Fourth, the researchers involved in public funded projects should benefit from the margin of freedom that private industry promises, both in the decision of research pathways and in their course. Finally, the scarcity of resources is likely to divert energy and attention of the public researchers and this aspect should be considered by decision makers when determining size and recipients of research funding.

[Good ending and better beginning. What future for medical journals?]

Scientific journals play an increasingly important role in the dissemination of research results, but also in the adoption of pharmaceutical innovation and technology in medicine. Healthcare decision makers are strongly influenced by the academic literature and for this reason medical journals should retain their independence and autonomy, preventing conflicts of interest. In a recently published editorial, the editor of the New England Journal of Medicine seems to be pleased with the results achieved. On the contrary, according to the editor of a respected specialized cardiovascular journal, Harlan Krumholz, journals are facing a number of important challenges. Medical journals are too expensive, too limited, too unreliable, too focused on wrong metrics, too powerful, too parochial, too static, and too dependent on a distorted model of business. In conclusion, medical journals do not seem to be the most appropriate educational tool in a scientific context that assigns value to transparency and sharing.

[Conflicts of interest: should we lower our guard?]

Conflicts of interest affect the scientific communication and information: their effects on the physician's prescribing behavior have been frequently studied and clearly documented. Recently, the New England Journal of Medicine published a series of papers questioning the radical positions on this topic, asking to reconsider the most intransigent approach, so that it may be possible a productive collaboration between academic medicine and pharmaceutical industry, in the interest of the patient. The papers published in the New England Journal of Medicine confirm the difficulties experienced by the biomedical journals: the support of the industry is essential and most of the authors and referees has ties with pharmaceutical or biotech companies. The debate among the various stakeholders is vital but should be open and transparent, with the aim to restore credibility to all the parties concerned: academic medicine, pharmaceutical industry and scientific publishers.

[The future of scientific libraries]

"Making predictions is always very difficult, especially about the future". Niels Bohr's quote is very appropriate when looking into the future of libraries. If the Web is now the richest library in the world, it is also the most friendly and therefore the most convenient. The evolution of libraries in the coming years - both traditional and online - will probably depend on their ability to meet the information needs of users: improved ease of use and better reliability of the information. These are objectives that require money and - given the general reduction in budgets - it is not obvious that the results will be achieved. However, there are many promising experiences at the international level that show that the world of libraries is populated by projects and creativity. Traditional or digital, libraries will increasingly present themselves more as a sharing tool than as a repository of information: it is the sharing that translates data into knowledge. In the healthcare field, the integration of online libraries with the epidemiological information systems could favor the fulfillment of unconscious information needs of health personnel; libraries will therefore be a key tool for an integrated answer to the challenge of continuing education in medicine. The Internet is no longer a library but an information ecosystem where the data are transformed into knowledge by sharing and discussion.

[Technology is changing: is the continuing professional development also changing?]

This paper considers the impact of the new information environment on the scientific communication. Reading behavior changes: today, we browse, scan, watch, receive an impression of something. The new reading habits are not simply determined by the new tools; they are rather influenced by the need to produce and share data and information, using personalized and mobile devices. Also the content formats change: researchers, clinicians, and nurses produce texts, figures, tables, photos, videos, tweets, blog posts and they share them to readers that have to collect, appraise, recombine and - most importantly - contextualize the information. This "continuous partial production" is consistent with a "continuous partial utilization" of data; this is a risk, but it is also an opportunity. On the one side, we risk a self-referential, individualized learning process; on the other side, we can enjoy the extraordinary chance to build a "shared learning environment", able to give a comprehensive solution to the challenges experienced by the health systems. Medical journals survive as valuable media to organize data and information; the new social web tools should support the traditional publishing patterns, to enhance the sharing of information, to help the appraisal of data, and to move forward new communities of learners.

Assessment of biosand filter performance in rural communities in southern coastal Nicaragua: an evaluation of 199 households

INTRODUCTION

Lack of access to safe drinking water is a major health issue for more than one billion people globally. In areas where community-wide water treatment is not possible, point-of-use (POU) solutions are necessary. The biosand filter (BSF) is one of several such POU technologies available to treat water in the home to reduce the risk of infection. This study was conducted to evaluate the use and performance of BSFs in the rural communities surrounding San Juan del Sur, Nicaragua. Approximately 600 filters had been installed in this area over the preceding 2 years by local workers supported by US and Canadian NGOs.

METHODS

This field study was conducted In July and August 2009. Unannounced household visits were carried out by US volunteers supported by a local interpreter and driver. Visits were made to a convenience sample of 199 households where BSFs had been in place for an average of 12 months. Water for analysis was collected from wells, filter spouts and storage buckets and an 11 item questionnaire was administered. Laboratory analyses were performed on water samples using the membrane filtration method to determine Escherichia coli colony forming units (CFUs).

RESULTS

Forty-five of 199 households visited had discontinued use of their BSF. In the 154 households tested, median CFU of E. coli per 100 mL of water from the source, filter spout and storage vessel were 313, 72, and 144, respectively. Median bacterial removal efficiency for the filters was 80%. Although biosand filtration reduced CFUs in 74% of households in which it was used, in only 26 cases (17%) did it reduce CFUs to <10 CFUs/100 mL. Recontamination was an important problem and reduced the overall efficacy (from well to storage bucket) to 48%. Participants were generally satisfied with their filter's performance, citing improved health and better tasting water.

CONCLUSION

Water quality testing of BSFs deployed in the field showed results somewhat inferior to previous reports. Possible explanations include lack of use of best practices and the inclusion of some filers in the analysis that may not have been in active use. Despite these results and high rates of recontamination in the storage bucket, most households members were pleased with their filters and claimed that their use had enhanced their health. This inconsistency could be due to inaccurate responses to the questionnaire for purposes of secondary gain.

[E-learning and the continuing professional development in medicine]

E-learning is widely used in continuing medical education but three main problems still face health decision makers: the substantial heterogeneity among the characteristics of the web-based educational projects; the concerns about the e-learning effectiveness; the variety of outcomes used to evaluate the effectiveness. Systematic reviews suggest e-learning has effectiveness similar to traditional educational methods.The attention should now be given to how and when can we use e-learning to improve the health workers' performance and better healthcare.

[The whole world in a cup of coffee. Case reports]

There is a rising interest for clinical cases in medicine. Actually, they don't necessarily conflict with the evidence-based medicine approach; rather, as several authors made clear, EBM-oriented case reports and clinical trials could be complementary. Cases and case series could even represent the first line of evidence and they are extremely valuable in discovering new pathologies and monitoring unexpected drug effects. They also play a relevant role in continuing medical education. The new section of Recenti Progressi in Medicina is edited by a prominent Italian research Institute (Istituto di Fisiologia Clinica, CNR). It focuses on a single case, guiding the physicians' decision-making from differential diagnosis to the treatment options.

[How to read medical journals. From ad hoc perusal to proactive reading to keep abreast of newly emerging evidence]

Physicians cannot practice good quality health care without updating their knowledge; reading is a key component of the continuing medical education, so their reading habits have been frequently studied in the past years. The information needs of doctors usually arise during the consultation and they are commonly related to the therapeutic and diagnostic strategy. Seeking answers to these questions from primary sources, such as medical journals, is time consuming and often discouraging. The just-in-time approach should be integrated by a "proactive monitoring for newly emerging evidence". Creating such a proactive system is not an easy task: time management, triage, teamwork, take home messages and tools are the critical steps to a successful lifelong learning. The aim of this paper is to help doctors to understand the better management of clinical knowledge, and to explain how to keep up professionally with the medical literature.

[How Scientific Publishing works]

Scientific, Technical and Medical Publishing (STM) is changing: the whole communication process (content production and delivery, distribution and dissemination) is involved in the change. The objective of this paper is to review some of the key issues currently faced by the publishing and scientific community; the review is also an attempt to provide a basic framework to clinical practitioners and researchers. The first section of the paper presents the main "facts and figures" of the STM landscape, following the mergers and acquisitions of the last 20 years. Then, the paper explains how the continual growth of catalogues, innovation and academic pressures generated new business models and publishing formats. Finally, the article considers the impact of the wider access to online information, on both publishers, authors and readers. In conclusion, the main concern expressed by the author is that the so-called "single-article economy" could probably be the next step of the STM publishing environment, in a perspective of a "just-in-time" usage of medical literature; this could represent a challenge for professional readers that will be less aware of brand and journal context, losing the opportunity to consider the single publishing items (papers, reviews, guidelines, etc.) in a deeper cultural framework.

[Web, workshops, e-learning for Quality improvement. An Evidence-based Medicine educational programme]

EBM is 15 years old. At present the main challenge seems to be to overcome the problems that prevent EBM from being widely adopted by physicians, nurses, and health managers. Several methods for teaching and learning EBM have been evaluated and an open debate on their efficacy is underway. EBM teaching must be considered as a preliminary step to the continuing medical education process and a prerequisite of continuing professional development aimed to making learning relational, ethical, and managerial skills easier. The Continuing Medical Education Office of the Autonomous Province of Bozen, Italy, started an educational programme aimed at disseminating the evidence-based approach in healthcare. Hospital doctors, general practitioners, nurses, psychologists and health managers must gain, apply, integrate, and share evidence-based knowledge in order to improve patient health. This paper reports the encouraging preliminary results of the Project, and explains the relevance of sharing and accessing a virtual medical library, integrated by consistent e-learning courses and by a series of educational meetings among a small number of participants. It also describes the next steps for completing the educational project.

Anaphylactoid reactions to vitamin K

Anaphylactoid reactions in patients receiving intravenously administered vitamin K have been reported in the literature. To summarize the known data on anaphylactoid reactions from administration of vitamin K, we reviewed all published and unpublished reports of this adverse reaction. Published reports were obtained through medline (1966--1999) and EMBASE (1971--1999) searches of the English language literature and review of references from identified case reports. Unpublished reports were obtained using the Spontaneous Reporting System Adverse Reaction database of the United States Food and Drug Administration (FDA) between August 1968 and September 1997. All adverse drug reactions to vitamin K were categorized by route of drug administration, dose and standard adverse reaction code. In the FDA reports, we defined anaphylactoid reactions as any adverse drug reaction coded as either anaphylaxis, allergic reaction, apnea, dyspnea, death, heart arrest, hypotension, shock or vasodilatation. Additionally, all fatal and life-threatening FDA reported reactions were reviewed to determine if they could represent an anaphylactoid reaction missed by the above definition. The literature review uncovered a total of 23 cases (3 fatal) of anaphylactoid reactions from intravenous vitamin K. The FDA database contained a total of 2236 adverse drug reactions reported in 1019 patients receiving vitamin K by all routes of administration. Of the 192 patients with reactions reported for intravenous vitamin K, 132 patients (69 %) had a reaction defined as anaphylactoid, with 24 fatalities (18 %) attributed to the vitamin K reaction. There were 21 patients with anaphylactoid reactions and 4 fatalities reported with doses of intravenous vitamin K of less than 5 mgs. For the 217 patients with reactions reported due to vitamin K via a non-intravenous route of administration, 38 patients had reactions meeting the definition of anaphylactoid (18 %), with 1 fatality (3 %) attributed to the drug. The absolute risk of an anaphylactoid reaction to intravenous vitamin K cannot be determined by this study, but the relatively small number of documented cases despite widespread use of this drug suggest that the reaction is rare. Anaphylactic reactions and case fatality reports were found even when intravenous vitamin K was given at low doses by slow dilute infusion. The pathogenesis of this reaction is unknown and may be multifactorial with etiologies including vasodilation induced by the solubilizing vehicle or immune-mediated processes. We conclude that use of intravenous vitamin K should be limited to patients with serious hemorrhage due to a coagulopathy that is secondary to a relative or absolute deficiency of vitamin K.

Automated detection of the factor V Leiden mutation using the LCx microparticle enzyme immunoassay

The factor V Leiden mutation, a G-->A transition at position 1691 in exon 10 of the gene that codes for factor V, produces an Arg506Gln substitution and is the most common genetic risk factor for venous thrombosis. We have developed a rapid, sensitive, and specific method to detect the factor V Leiden mutation in genomic DNA from whole blood by PCR amplification and microparticle enzyme immunoassay detection using the Abbott LCx instrument. We compared this automated method with the standard procedure using restriction endonuclease digestion of PCR products followed by gel electrophoresis in blinded experiments. In 130 patients (from Veterans Affairs medical centers) with deep venous thromboses, including 24 heterozygotes with the factor V Leiden mutation, there was complete agreement between the two methods. The assay was also able to distinguish heterozygotes from homozygotes. This method, which carries a low potential for cross-contamination of samples, should be a useful routine test for the factor V Leiden mutation in clinical laboratories with sufficient demand for molecular diagnostic assays using the LCx instrument.

Anticoagulation: risks and benefits in atrial fibrillation

Anticoagulation with warfarin has been shown to be effective in preventing ischemic stroke in patients with atrial fibrillation. However, physicians have been reluctant to prescribe this therapy for patients age 60 and older because of the associated risk of bleeding during antithrombotic therapy. Four clinical features independently increase the risk of stroke in individuals with atrial fibrillation: previous stroke or transient ischemic attack, diabetes, history of hypertension, and advancing age. In individual patients, bleeding complications can be reduced by eliminating loading doses, monitoring therapy frequently during the initiation phase, targeting lower INRs, recognizing the potential for drug interactions, and identifying clinical risk factors.

Efficacy and safety of combined anticoagulant and antiplatelet therapy versus anticoagulant monotherapy after mechanical heart-valve replacement: a metaanalysis

We performed a metaanalysis of five randomized controlled trials to compare the efficacy and safety of combined oral anticoagulant and antiplatelet therapy versus oral anticoagulants alone after prosthetic heart-valve replacement. The combined regimen reduced embolism and overall mortality by approximately 67% (pooled odds ratio [OR] 0.33; 95% confidence interval [CI] 0.16 to 0.69; p = 0.0032) and 40% (OR 0.60; 95% CI 0.32 to 1.12; p = 0.11), respectively, but increased the risk of hemorrhage by approximately 65% (OR 1.65; 95% CI 1.15 to 2.39; p = 0.0069) and of major gastrointestinal hemorrhage by approximately 250% (OR 3.47; 95% CI 1.43 to 8.40; p = 0.0058). It is estimated that for every 1.6 patients who had their stroke prevented by combination therapy, there was an excess of one major gastrointestinal bleed. This metaanalysis suggests that the benefits derived from the enhanced antithrombotic potential of combined therapy outweigh the toxic effects resulting from the enhanced anticoagulant potential of this regimen.

Real-time digital control of optical interferometers by the mechanical-modulation technique

We discuss the application of digital systems to the automatic control of dual-wave optical interferometers. We show that, if the mechanical-modulation technique is used for error-signal extraction, digital techniques can be used both for error-signal extraction and for control-signal generation. Therefore, apart from two front/end amplifiers that are necessary to match the dynamics of the detectors and actuators to the dynamics of the analog-to-digital converters and digital-to-analog converters, no other analog devices are required. In particular, the mechanical-modulation technique requires the synchronous demodulation of the photodiode output signal. Hence we need to implement a digital lock-in amplifier whose algorithm is described here. Finally, we describe one of the possible applications of this digital control procedure, such as the control of a classic Mach-Zehnder interferometer in air.

Mechanisms of hemostasis and arterial thrombosis

The term hemostasis refers to the critical physiologic response to arterial injury that serves to limit hemorrhage. Thrombosis, a pathologic process, results when the coagulation system is excessively activated in the absence of bleeding. The mechanisms that regulate these processes, as well as the mode of action of pharmacologic agents that attenuate thrombosis, are discussed.

Use of antiplatelet agents and anticoagulants in post-myocardial infarction

This article addresses the efficacy and safety of antiplatelet and anticoagulant agents following acute myocardial infarction. Major trials are reviewed for both of these treatment modalities in the order in which they were published. Accompanying editorial comments highlight the key findings of the studies and places them in historical context. Current recommendations for treatment are summarized. Antithrombotic therapy used as an adjuvant to thrombolytic therapy is discussed elsewhere.

Comparison of a standard and a sensitive thromboplastin in monitoring low intensity oral anticoagulant therapy

The greater precision in prothrombin time monitoring obtained using thromboplastins with low international sensitivity index (ISI) values are believed to result in improved patient care. The authors conducted a blinded prospective study of 84 random patients on low-intensity warfarin therapy who were monitored with either a sensitive (ISI, 1.3) or standard (ISI, 1.9) thromboplastin. For the patients monitored with standard and sensitive thromboplastins, respectively, no difference was found in the degree of anticoagulation (standard thromboplastin mean INR, 2.4 vs. 2.5, P = .37; sensitive thromboplastin mean INR, 2.6 vs. 2.6, P = .74; mean daily warfarin dose, 5.1 vs. 4.7 mg, P = .28) or efficacy (warfarin dosage adjustments, 117 vs. 116; clinic visits, 362 vs. 378; percentage of therapeutic INR determinations, 47% vs. 48%). In addition, no difference was found in bleeding prevalence or severity (.22 vs. .27 events per person-year observation). The authors concluded that monitoring anticoagulant therapy in the INR range of 2-3 with a standard thromboplastin may be comparable to monitoring with a more sensitive thromboplastin with respect to efficacy, safety, and degree of anticoagulation achieved.

Fringe-counting technique used to lock a suspended interferometer

We implement a digital fringe-counting technique to measure in real time the relative mirror displacement of a suspended Michelson interferometer with modulated optical path length for oscillations much larger than the laser wavelength (λ). This provides the proper error signal for a servo mechanism that reduces the relative displacement within λ/2. The implemented technique does not require extra optics or polarizers and thus can be used for interferometric gravitational wave detectors as a starting procedure to get the system locked.

A clinical study monitoring low-intensity anticoagulant therapy with a standard-sensitivity thromboplastin

The ability of the prothrombin time to measure the anticoagulant effect of warfarin sodium varies depending on the particular tissue thromboplastin used in performing the test. Based on studies using sensitive thromboplastins, lower therapeutic ranges of anticoagulation are recommended. The adequacy of monitoring therapy in this lower range with the relatively insensitive thromboplastins commonly used in North America is unestablished. This 16-month prospective study used a standard North American thromboplastin to monitor 157 anticoagulated patients treated in a low therapeutic range. Of the 1734 prothrombin times generated, 876 (56%) were therapeutic, with 400 (23%) below and 458 (26%) above the therapeutic range. These results are comparable with those published in trials in which more sensitive thromboplastins were used in a similar therapeutic range. We conclude that standard North American thromboplastins are adequately suited to monitor therapy in this lower range.

Detection of intracoronary fibrin degradation after coronary balloon angioplasty

Intracoronary thrombus formation may be involved in the pathogenesis of arterial closure after coronary angioplasty and may contribute to restenosis. It is hypothesized that, unlike markers of platelet activation and fibrin formation, D-dimer, a product of plasmin-mediated proteolysis of cross-linked fibrin, is not subject to significant catheter-induced artifact and could be used to study intracoronary fibrin degradation during angioplasty. No significant difference in D-dimer levels was noted in serial plasma samples obtained from an 8Fr arterial sheath and the wire lumen of an angioplasty balloon catheter, indicating that sampling through the catheter lumen did not induce artifactual D-dimer elevations. Translesion (proximal and distal to the lesion) coronary blood samples were collected in 31 patients undergoing elective coronary angioplasty pretreated with aspirin, dipyridamole and heparin. In 20 of those in whom translesion coronary samples for plasma D-dimer levels (mean +/- standard deviation) were collected before balloon dilation, there was no evidence of ongoing intracoronary fibrinolysis (proximal D-dimer levels, 289 +/- 145 ng/ml; distal, 299 +/- 156 ng/ml; difference not significant). After coronary angioplasty (n = 31), there was a relatively small, but significant (p less than 0.001) increase (45 +/- 71 ng/ml) in translesional D-dimer levels (proximal, 396 +/- 223 ng/ml; distal, 441 +/- 257 ng/ml). The results from this study suggest (1) D-dimer levels are not subject to significant catheter-induced artifact and may be useful for assessment of intracoronary fibrin metabolism, and (2) intracoronary degradation of fibrin can be detected after (but not before) routine coronary angioplasty despite pretreatment with antithrombotic therapy, presumably in response to balloon-induced arterial injury and fibrin formation.

The bleeding time response to aspirin. Identifying the hyperresponder

The authors measured the template bleeding time in 11 normal people before and 2, 4, 12, 24, and 48 hours after the subjects ingested a single dose of 74 mg of aspirin (ASA). The entire experiment was repeated twice at two-week intervals, with the dose of ASA increased to 325 mg and finally 3,900 mg. The mean increase was maximal at 4 and 12 hours, regardless of the dose administered, with a return to baseline by 48 hours. The authors then performed bleeding times in a prospective randomized double-blinded fashion on an additional 39 subjects at baseline and seven hours after they ingested either placebo or ASA 325 mg. The mean baseline bleeding time was 5.2 minutes (SD +/- 1.4), with a mean prolongation after ASA of 2.1 minutes (SD +/- 1.9). The authors identified 5 of 37 (14%) subjects as hyper-responders (HRs) using the criterion of a bleeding time prolongation of greater than 5.9 minutes (greater than 2 SD beyond the mean prolongation). Neither baseline bleeding time, threshold sensitivity of collagen-induced platelet aggregation, nor other tests of hemostatic function discriminated HRs from normals. The authors conclude that in subjects with normal baseline bleeding times, a prolongation of greater than 5.9 minutes when measured seven hours after the administration of a single dose of 325 mg of ASA can discriminate HRs from normals.