Which Patients with Atrial Fibrillation Do Not Need Anticoagulation Therapy with Warfarin?

Anticoagulation therapy with warfarin is not indicated for use in patients with non- valvular atrial fibrillation who are at low risk for embolic cerebral vascular events. The classification of "low risk for embolic stroke" is defined as a 1 percent annual risk for stroke or lone atrial fibrillation (i.e., age younger than 65 years without history of hypertension, transient ischemic attack, stroke, coronary heart disease, recent congestive heart failure, or diabetes). Anticoagulation therapy with warfarin is beneficial in patients with atrial fibrillation who are at moderate or high risk for stroke. Patients with absolute contraindications to anticoagulation therapy (e.g., thrombocytopenia, recent trauma or surgery, hemorrhagic stroke, alcoholism) should not take warfarin. [Strength of recommendation: A, based on meta-analyses of large randomized controlled trials (RCTs).

Particle Acceleration at Ultra-Relativistic Shocks and the Spectra of Relativistic Fireballs

We examine Fermi-type acceleration at relativistic shocks, and distinguish between the initial boost of the first shock crossing cycle, where the energy gain per particle can be very large, and the Fermi process proper with repeated shock crossings, in which the typical energy gain is of order unity. We calculate by means of numerical simulations the spectrum and angular distribution of particles accelerated by this Fermi process, in particular in the case where particle dynamics can be approximated as small-angle scattering. We show that synchrotron emission from electrons or positrons accelerated by this process can account remarkably well for the observed power-law spectra of GRB afterglows and Crab-like supernova remnants. In the context of a decelerating relativistic fireball, we calculate the maximum particle energy attainable by acceleration at the external blast wave, and discuss the minimum energy for this acceleration process and its consequences for the observed spectrum.Comment: To appear in Proceedings of the 5th Huntsville Gamma-Ray Burst Symposium. LaTeX, 6 pages, 2 figures, uses aipproc.sty and epsfi

An eigenfunction method for particle acceleration at ultra-relativistic shocks

We adapt and modify the eigenfunction method of computing the power-law spectrum of particles accelerated at a relativistic shock front via the first-order Fermi process (Kirk, J.G., Schneider, P., Astrophysical Journal 315, 425 (1987)) to apply to shocks of arbitrarily high Lorentz factor. The power-law index of accelerated particles undergoing isotropic small-angle scattering at an ultrarelativistic, unmagnetized shock is found to be s=4.23 +/- 0.2 (where s=d\ln f/ d\ln p, with f the Lorentz-invariant phase-space density and p the momentum), in agreement with the results of Monte-Carlo simulations. We present results for shocks in plasmas with different equations of state and for Lorentz factors ranging from 5 to infinity.Comment: 4 pages, 2 figures, contribution to the Proceedings of the 5th Huntsville GRB Symposiu

When should you consider implanted nerve stimulators for lower back pain?

Patients can gain more pain relief from spinal cord stimulation (SCS) than from reoperation (strength of recommendation [SOR]: A, 2 randomized controlled trials [RCTs]). SCS can also treat chronic low back pain effectively (SOR: B, cohort studies). It's indicated when conservative measures have failed (SOR: C, expert opinion). The side effects and failure rates of SCS are well documented and should be considered before recommending the therapy to patients (SOR: A, systematic review of RCTs and cohort studies)

Which treatments are effective for cervical radiculopathy?

Initial treatment options comprise rest, cervical immobilization, anti-inflammatory drugs (nonsteroidal and steroidal), pain relievers (including muscle relaxants and antiepileptics), and physical therapy (strength of recommendation [SOR]: B, cohort studies). As many as 60% of patients who fail initial treatments report long-term pain relief with epidural corticosteroid injections (SOR : C, case series)

Low efficacy of the combination artesunate plus amodiaquine for uncomplicated falciparum malaria among children under 5 years in Kailahun, Sierra Leone.

OBJECTIVE: In 2004, Sierra Leone adopted artesunate plus amodiaquine as first-line antimalarial treatment. We evaluated the efficacy of this combination in Kailahun, where a previous study had shown 70.2% efficacy of amodiaquine in monotherapy. METHODS: Method and outcome classification of the study complied with WHO guidelines. Children 6-59 months with uncomplicated malaria were followed-up for 28 days. PCR genotyping was used to distinguish recrudescence from reinfection. Reinfections were reclassified as cured. RESULTS: Of 172 children who were referred to the study clinic, 126 satisfied inclusion criteria and were enrolled. No early treatment failures were reported. The day 14, efficacy was 98.2% (95% CI: 93.8-99.8). Of 65 recurrent parasitaemias analysed by PCR, 17 were recrudescences. The PCR-adjusted day 28 efficacy was 84.5% (95% CI: 76.4-90.7). All true failures occurred in the last 8 days of follow-up. Of 110 children who completed the 28-day follow-up, 54 (49.1%) experienced a novel infection. CONCLUSION: The efficacy of this combination was disappointing. The high reinfection rate suggested little prophylactic effect. In Kailahun a more efficacious combination might be necessary in the future. The efficacy of AS + AQ needs to be monitored in Kailahun and in the other regions of Sierra Leone

Combined Oral Contraceptives for Mothers Who Are Breastfeeding

There is currently no evidence of harm; however, few patients have been studied and existing studies have many limitations. Therefore, it is not possible to definitively answer this question at this time. The existing low-quality evidence suggests that combined oral contraceptives may reduce the volume of breast milk but not affect the growth of infants. [Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence

Adherence to a Six-Dose Regimen of Artemether-Lumefantrine for Treatment of Uncomplicated Plasmodium Falciparum Malaria in Uganda.

Measuring baseline levels of adherence and identifying risk factors for non-adherence are important steps before the introduction of new antimalarials. In Mbarara in southwestern Uganda, we assessed adherence to artemether-lumefantrine (Coartem) in its latest World Health Organization blister formulation. Patients with uncomplicated Plasmodium falciparum malaria were prescribed artemether-lumefantrine and received an explanation of how to take the following five doses at home. A tablet count was made and a questionnaire was completed during a home visit. Among 210 analyzable patients, 21 (10.0%) were definitely or probably non-adherent, whereas 189 (90.0%) were probably adherent. Age group was not associated with adherence. Lack of formal education was the only factor associated with non-adherence after controlling for confounders (odds ratio = 3.1, 95% confidence interval [CI] = 1.1-9.7). Mean lumefantrine blood levels were lower among non-adherent (n = 16) (2.76 microg/mL, 95% CI = 1.06-4.45) than among adherent (n = 171) (3.19 microg/mL, 95% CI = 2.84-3.54) patients, but this difference was not statistically significant. The high adherence to artemether-lumefantrine found in our study suggest that this drug is likely to be very effective in Mbarara provided that patients receive clear dosage explanations

Death rates from malaria epidemics, Burundi and Ethiopia.

Death rates exceeded emergency thresholds at 4 sites during epidemics of Plasmodium falciparum malaria in Burundi (2000-2001) and in Ethiopia (2003-2004). Deaths likely from malaria ranged from 1,000 to 8,900, depending on site, and accounted for 52% to 78% of total deaths. Earlier detection of malaria and better case management are needed

How should we manage a patient with a positive PPD and prior BCG vaccination?

Prior bacille Calmette-Guérin (BCG) vaccination increases the likelihood of a positive tuberculosis (TB) 5TU purified protein derivative (PPD) skin test. The PPD response following BCG vaccine varies with age at vaccination, number of years since the BCG vaccination, number of times vaccinated, and number of PPDs performed. An induration of greater than 14 mm is unlikely to be due to prior BCG vaccination (strength of recommendation [SOR]: A, based on meta-analysis of validation cohort studies)