Bleeding with direct oral anticoagulants vs warfarin: clinical experience.

The risk of bleeding in the setting of anticoagulant therapy continues to be re-evaluated following the introduction of a new generation of direct oral anticoagulants (DOACs). Interruption of DOAC therapy and supportive care may be sufficient for the management of patients who present with mild or moderate bleeding, but in those with life-threatening bleeding, a specific reversal agent is desirable. We review the phase 3 clinical studies of dabigatran, rivaroxaban, apixaban, and edoxaban in patients with nonvalvular atrial fibrillation, in the context of bleeding risk and management

Engagement, gamification, and workplace satisfaction: A convergent study of user indicators

The purpose of this study was to determine if there was a correlation between the personal indicators of gamification users, game preferences, and workplace engagement. A three-part survey was deployed through an online, opt-in gamification platform in order to gauge individual user preferences

Cerebral Blood Flow in Relation to Contralateral Carotid Disease an MRA and TCD Study

AbstractObjective: to describe redistribution of cerebral blood flow in patients with severe internal carotid artery (ICA) stenoses in relation to contralateral ICA disease. Methods: sixty-six patients scheduled for carotid endarterectomy (CEA) were grouped according to severity of contralateral stenosis (<30% [group I]; 30–69% [group II]; 70–99% [group III]; occlusion [group IV]. Transcranial Doppler (TCD) and magnetic resonance angiography (MRA) investigations were performed preoperatively. Results: TCD demonstrated a reversed flow in the contralateral anterior cerebral artery (A1segment) and ophthalmic artery in three-quarters of group IV patients (p <0.0001). Group IV patients also exhibited decreased blood flow velocity in the contralateral middle cerebral artery (p =0.001). MRA showed increased ipsilateral ICA and basilar artery (BA) blood flow volumes (Q-flows) in group IV patients when compared to the other groups (p <0.001). No changes in total Q-flow (ICAs+BA) were found. Conclusions: in patients considered for CEA, the severity of the contralateral ICA disease is an important determinant of the pattern of blood flow redistribution through the anterior communicating pathway and ophthalmic artery. Significant flow redistribution through the posterior communicating pathway occurs especially in patients with contralateral ICA occlusion

The effect of homocysteine-lowering with B-vitamins on osteoporotic fractures in patients with cerebrovascular disease: substudy of VITATOPS, a randomised placebo-controlled trial

10.1186/1471-2318-13-88BMC Geriatrics131

The impact of hunting on tropical mammal and bird populations

Hunting is a major driver of biodiversity loss, but a systematic large-scale estimate of hunting-induced defaunation is lacking. We synthesized 176 studies to quantify hunting-induced declines of mammal and bird populations across the tropics. Bird and mammal abundances declined by 58% (25 to 76%) and by 83% (72 to 90%) in hunted compared with unhunted areas. Bird and mammal populations were depleted within 7 and 40 kilometers from hunters’ access points (roads and settlements). Additionally, hunting pressure was higher in areas with better accessibility to major towns where wild meat could be traded. Mammal population densities were lower outside protected areas, particularly because of commercial hunting. Strategies to sustainably manage wild meat hunting in both protected and unprotected tropical ecosystems are urgently needed to avoid further defaunation

Does clinician continuity influence hearing aid outcomes?

OBJECTIVE : To evaluate whether clinician continuity is associated with successful hearing aid outcomes. DESIGN : A prospective cohort study. Clinician continuity was defined as occurring when apatient was cared for by the same clinician for the hearing assessment, hearing aid selection process, hearing aid fitting and programming, and subsequent hearing aid fine tuning appointments. The hearing aid outcome measures included self-reported hearing aid use,benefit and satisfaction as well as self-reported handling skills and problems experienced with hearing aids. STUDY SAMPLE : Four hundred and sixty-eight adult hearing aid users (mean age 73.9 years ± 10.9) and 26 qualified audiologists (mean age 34 years ± 6.34) recruited from a single hearing clinic in Perth, Western Australia. RESULTS : There were no significant differences in hearing aid outcomes between participants who experienced clinician continuity and those who did not. CONCLUSIONS : Within a controlled practice setting, hearing aid outcomes may not be adversely effected if services are provided by more than one clinician.R. Bennett is funded by an Australian postgraduate award scholarship through the School of Surgery at The University of Western Australia.http://www.tandfonline.com/loi/iija202017-05-31hb2017Speech-Language Pathology and Audiolog

Auditory-cognitive training for adult cochlear implant recipients : a study protocol for a randomised controlled trial

BACKGROUND: There is an urgent need to develop new therapies to improve cognitive function in adults following cochlear implant surgery. This study aims to determine if completing at-home computer-based brain training activities improve memory and thinking skills in adults following their first cochlear implant. METHODS: This study will be conducted as a single-blind, head-to-head, randomised controlled trial (RCT). It will determine whether auditory training combined with adaptive computerised cognitive training will elicit greater improvement in cognition, sound and speech perception, mood, and quality of life outcomes in adult cochlear implant recipients, when compared to auditory training combined with non-adaptive (i.e. placebo) computerised cognitive training. Participants 18 years or older who meet the clinical criteria for a cochlear implant will be recruited into the study. RESULTS: The results of this trial will clarify whether the auditory training combined with cognitive training will improve cognition, sound and speech perception, mood, and quality of life outcomes in adult cochlear implant recipients. DISCUSSION: We anticipate that our findings will have implications for clinical practice in the treatment of adult cochlear implant recipients.William Demant Foundation and Ear Science Institute Australia.http://www.trialsjournal.compm2022Speech-Language Pathology and Audiolog

Balancing the Benefits and Risks of 2 Doses of Dabigatran Compared With Warfarin in Atrial Fibrillation

ObjectivesThis study sought to compare the net clinical benefit of dabigatran 110 mg bid and 150 mg bid with that of warfarin in patients with atrial fibrillation (AF).BackgroundIn patients with AF, dabigatran 110 mg bid and 150 mg bid are associated with similar rates of death. However, the higher dose reduces ischemic stroke and increases bleeding compared with the lower dose. Therefore, there is uncertainty about how to evaluate the overall benefit of the 2 doses.MethodsIn 18,113 AF patients in the RE-LY (Randomized Evaluation of Long Term Anticoagulant Therapy) trial, we used a previously developed method for integrating ischemic and bleeding events as “ischemic stroke equivalents” in order to compare a weighted benefit of 2 doses of dabigatran with each other, and with that of warfarin.ResultsCompared with warfarin, there was a significant decrease in ischemic stroke equivalents with both dabigatran doses: –0.92 per 100 patient years (95% confidence interval [CI]: –1.74 to −0.21, p = 0.02) with dabigatran 110 mg bid and –1.08 (95% CI: –1.86 to −0.34, p = 0.01) with dabigatran 150 mg bid. There was no significant difference in ischemic stroke equivalents between the 2 doses: –0.16 (95% CI: –0.80 to 0.43) comparing dabigatran 150 mg bid with 110 bid. When including death in the weighted benefit calculations, the results were similar.ConclusionsOn a group level both doses of dabigatran as compared with warfarin have similar benefits when considering a weighted estimate including both efficacy and safety. The similar overall benefits of the 2 doses of dabigatran versus warfarin support individualizing the dose based on patient characteristics and physician and patient preferences. (Randomized Evaluation of Long Term Anticoagulant Therapy [RE-LY] With Dabigatran Etexilate; NCT00262600

Quality of life after infrainguinal bypass grafting surgery

AbstractPurpose: The purpose of this study was to compare quality of life in patients with and without various ischemic complications after infrainguinal bypass grafting surgery for occlusive vascular disease. Methods: A sample of patients (n = 746) randomized in the Dutch BOA study (n = 2645), a multicenter trial that compared the effectiveness of oral anticoagulant therapy with aspirin in the prevention of infrainguinal bypass graft occlusions, was entered in this study. On the basis of clinical outcomes of the trial, the patients were grouped as follows: patients with patent grafts (n = 409); patients with nontreated graft occlusions, subdivided into an asymptomatic group (n = 32) and a symptomatic group (n = 65); patients with subsequent revascularizations (n = 194); patients with amputations (n = 36); and patients with failed secondary revascularizations followed by secondary amputation (n = 38). In case an outcome event occurred, the patients were regrouped accordingly. Every half year, the patients completed a Short Form–36 and a EuroQol questionnaire. A multilevel model was used for repeated measure analysis. Results:The mean follow-up time was 21 months. The quality of life in patients with nontreated asymptomatic occlusions was roughly similar to the quality of life in patients with patent grafts. Patients with symptomatic nontreated occlusions had the lowest outcome with regard to pain as compared with the other groups. Furthermore, physical and social functioning was lower for these patients than for patients with patent grafts. Revascularizations, successful or not, negatively affected pain, social functioning, and physical and emotional role. After successful revascularization, some improvement was observed in pain, physical and social functioning, and general and mental health as compared with the group with nontreated symptomatic occlusions. Amputation deteriorated physical functioning strikingly, especially after failed secondary revascularization. These patients also had the lowest scores of all the groups in the dimensions of social functioning, physical and emotional role, and mental health. EuroQol score showed deterioration of quality of life after all events, except for asymptomatic occlusions. The same patterns emerged if we stratified our analysis according to the indication for the initial operation: claudication or limb salvage. Quality of life was constant over time in all the groups in the observed period. Conclusion: Quality of life in patients with asymptomatic occluded grafts is similar to quality of life in patients with patent grafts. Revascularization of symptomatic occluded grafts improves quality of life to a certain extent. Amputation, in particular after failed secondary revascularization, seemed to be the lowest possible outcome. The results of the Short Form-36 and EuroQol measurements were in line with the clinical expectations. The association of disease severity with scores on the instruments supports the construct validity of these outcome measures for an objective assessment of quality of life in controlled studies. (J Vasc Surg 1999;29:913-9.