Quality of Life and Treatment Satisfaction Among Patients on Long Term Oral Anticoagulant in A Developing Country

Background: Randomised phase III studies had proven the efficacy and safety profile of direct oral anticoagulant (DOAC) over warfarin in stroke and systemic embolism prevention for patients with atrial fibrillation (AF) and venous thromboembolism (VTE). Nevertheless, patients’ quality of life (QOL) and treatment satisfaction was not explored in these studies. Objective: The primary objective of this study was to compare the QOL and treatment satisfaction of patients on long term warfarin versus DOACs in a tertiary hospital in Malaysia. Methods: This is a cross-sectional study of patients with nonvalvular AF (NVAF) or VTE on long term warfarin versus DOACs attending the cardiology clinic and anticoagulation clinic of University Malaya Medical Centre from 1 st July 2016 to 30 st June 2018. Patients’ QOL was assessed by using Short Form 12v2 Health Survey (SF12v2); while treatment satisfaction was assessed by using Perception of Anticoagulation Treatment Questionnaire 2 (PACT-Q2). Results: Of 208 patients, 52.4% received warfarin and remaining 47.6% received DOACs. The warfarin group was significantly younger and had longer treatment duration (p b 0.001); while DOAC group had significant more underlying NVAF (p b 0.001) and polypharmacy (p= 0.003). There was no significant difference in the score of physical component summary (PCS) (p= 0.083), mental component summary (MCS) (p = 0.665) and each domain of SF-12v12 (p = 0.058 – 0.953) between anticoagulant groups. There were no differences between the 2 groups of anticoagulants even after adjustment of age. The satisfactionscore was significant higher in DOACs group compared to warfarin group (p = 0.003); but there was no difference in the convenience score (p= 0.234). Hospitalisation rate was significantly higher (p = 0.002) in warfarin group. Only 45.0% of patients achieved good time in therapeutic range (TTR). Conclusions: Despite no significant difference in QOL, patients with AF or VTE who were treated with DOACs demonstrated better efficacy, safety, and satisfaction profile, as well as a relatively stable within-group QOL

Symptomatic anaemia 17 years after double valve replacement

A 40-year-old Malay woman presented with increasing lethargy, palpitation and shortness of breath, 17 years after a mitral and aortic valve replacement. A Starr-Edwards prosthetic valve replaced the mitral valve, and a Bjork-Shiley prosthetic valve replaced the aortic valve. Biochemical parameters demonstrated intravascular haemolysis, as evidenced by haemoglobin 7.8 g/dL, reticulocyte count 8.4%, lactate dehydrogenase 2,057 IU/L and low haptoglobulin levels (less than 6 mg/dL). Transoesophageal echocardiography revealed a paravalvular leakage over the mitral valve. The haemoglobin levels remained persistently low despite frequent blood transfusions. She successfully underwent a second mitral valve replacement. Her anaemia resolved subsequently

Factors associated with abrupt discontinuation of dabigatran therapy in patients with atrial fibrillation in Malaysia

Background Oral anticoagulant therapy is indicated for the prevention of stroke or other thromboembolic events. Premature discontinuation of oral anticoagulants may increase the risk of thromboembolism resulting in adverse sequelae. There are sparse data on the prevalence and the predictors of dabigatran discontinuation in Malaysian patients with atrial fibrillation. Objectives Determine the reasons and identify associated factors for abrupt discontinuation of dabigatran, assess the switching pattern and the occurrence of thromboembolic events after dabigatran discontinuation. Setting A university-affiliated tertiary hospital in Kuala Lumpur, Malaysia. Methods The clinical and demographic data of a cohort who were initiated with dabigatran between 2010 and 2012 at the University of Malaya Medical Centre were reviewed until the date of death or on 31st December 2013. Those patients who discontinued dabigatran were further followed up until 31st December 2015 to determine the occurrence of any thromboembolic event. Main outcome measure Permanent discontinuation of dabigatran for more than 8 weeks. Results 26 (14 %) of a cohort of 192 patients discontinued dabigatran therapy during a median follow-up period of 20 (range 3–45) months. About one-half of the discontinuation occurred within the first 6 months of dabigatran use. The three most cited reasons for discontinuation are bleeding events (19 %), high out-of-pocket drug payment (19 %) and cardioversion (19 %). Heart failure [adjusted odds ratio 3.699 (95 % confidence interval 1.393–9.574)] or chronic kidney disease [adjusted odds ratio 5.211 (95 % confidence interval 1.068–23.475)] were found to be independent risk factors for abrupt dabigatran discontinuation. Patients who discontinued dabigatran received warfarin (38 %), antiplatelet agents (16 %) or no alternative antithrombotic therapy (46 %). Five of the 26 patients who discontinued dabigatran developed an ischaemic stroke within 3–34 months after discontinuation. Conclusion Abrupt dabigatran discontinuation without an alternative oral anticoagulant increases the risk of thromboembolic events. As adverse drug events and renal impairment contribute substantially to the premature discontinuation of dabigatran, it is important to identify and monitor patients at risk to reduce dabigatran discontinuation rate especially during the first six months of dabigatran therapy

Surgery for Retroperitoneal Sarcoma Requiring Major Vascular Resection and Reconstruction

Retroperitoneal sarcomas are characterized by a lack of early symptoms; the inevitable delay in diagnosis results in large sizes at presentation. The current standard of care for these tumours is complete oncological resection with microscopically negative margins. In a subset of these tumours, major vessels such as the inferior vena cava or aorta are involved and resection of these major vessels becomes necessary for complete oncological clearance. This paper describes a series of these tumours and demonstrates the feasibility of radical surgery and resection of major vessels with low morbidity

Leveraging machine learning techniques and engineering of multi-nature features for national daily regional ambulance demand prediction

10.3390/ijerph17114179International Journal of Environmental Research and Public Health171115-Ja