Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF):a randomised, open-label, phase 2 trial

Background In patients with atrial fibrillation who survive an anticoagulation-associated intracerebral haemorrhage, a decision must be made as to whether restarting or permanently avoiding anticoagulation is the best long-term strategy to prevent recurrent stroke and other vascular events. In APACHE-AF, we aimed to estimate the rates of non-fatal stroke or vascular death in such patients when treated with apixaban compared with when anticoagulation was avoided, to inform the design of a larger trial. Methods APACHE-AF was a prospective, randomised, open-label, phase 2 trial with masked endpoint assessment, done at 16 hospitals in the Netherlands. Patients who survived intracerebral haemorrhage while treated with anticoagulation for atrial fibrillation were eligible for inclusion 7-90 days after the haemorrhage. Participants also had a CHA2DS2-VASc score of at least 2 and a score on the modified Rankin scale (mRS) of 4 or less. Participants were randomly assigned (1:1) to receive oral apixaban (5 mg twice daily or a reduced dose of 2.5 mg twice daily) or to avoid anticoagulation (oral antiplatelet agents could be prescribed at the discretion of the treating physician) by a central computerised randomisation system, stratified by the intention to start or withhold antiplatelet therapy in participants randomised to avoiding anticoagulation, and minimised for age and intracerebral haemorrhage location. The primary outcome was a composite of non-fatal stroke or vascular death, whichever came first, during a minimum follow-up of 6 months, analysed using Cox proportional hazards modelling in the intention-to-treat population. APACHE-AF is registered with ClinicalTrials.gov (NCT02565693) and the Netherlands Trial Register (NL4395), and the trial is closed to enrolment at all participating sites. Findings Between Jan 15, 2015, and July 6, 2020, we recruited 101 patients (median age 78 years [IQR 73-83]; 55 [54%] were men and 46 [46%] were women; 100 [99%] were White and one [1%] was Black) a median of 46 days (IQR 21-74) after intracerebral haemorrhage. 50 were assigned to apixaban and 51 to avoid anticoagulation (of whom 26 [51%] started antiplatelet therapy). None were lost to follow-up. Over a median follow-up of 1.9 years (IQR 1.0-3.1; 222 person-years), non-fatal stroke or vascular death occurred in 13 (26%) participants allocated to apixaban (annual event rate 12.6% [95% CI 6.7-21.5]) and in 12 (24%) allocated to avoid anticoagulation (11.9% [95% CI 6.2-20.8]; adjusted hazard ratio 1.05 [95% CI 0.48-2.31]; p=0.90). Serious adverse events that were not outcome events occurred in 29 (58%) of 50 participants assigned to apixaban and 29 (57%) of 51 assigned to avoid anticoagulation. Interpretation Patients with atrial fibrillation who had an intracerebral haemorrhage while taking anticoagulants have a high subsequent annual risk of non-fatal stroke or vascular death, whether allocated to apixaban or to avoid anticoagulation. Our data underline the need for randomised controlled trials large enough to allow identification of subgroups in whom restarting anticoagulation might be either beneficial or hazardous. Copyright (C) 2021 Elsevier Ltd. All rights reserved

Risk factors for atherosclerotic and medial arterial calcification of the intracranial internal carotid artery

_Background and aims:_ Calcifications of the intracranial internal carotid artery (iICA) are an important risk factor for stroke. The calcifications can occur both in the intimal and medial layer of the vascular wall. The aim of this study is to assess whether medial calcification in the iICA is differently related to risk factors for cardiovascular disease, compared to intimal calcification. _Methods:_ Unenhanced thin slice computed tomography (CT) scans from 1132 patients from the Dutch acute stroke study cohort were assessed for dominant localization of calcification (medial or intimal) by one of three observers based on established methodology. Associations between known cardiovascular risk factors (age, gender, body mass index, pulse pressure, eGFR, smoking, hypertension, diabetes mellitus, hyperlipidemia, previous vascular disease, and family history) and the dominant localization of calcifications were assessed via logistic regression analysis. _Results:_ In the 1132 patients (57% males, mean age 67.4 years [SD 13.8]), dominant intimal calcification was present in 30.9% and dominant medial calcification in 46.9%. In 10.5%, no calcification was seen. Age, pulse pressure and family history were risk factors for both types of calcification. Multivariably adjusted risk factors for dominant intimal calcification only were smoking (OR 2.09 [CI 1.27–3.44]) and hypertension (OR 2.09 [CI 1.29–3.40]) and for dominant medial calcification diabetes mellitus (OR 2.39 [CI 1.11–5.14]) and previous vascular disease (OR 2.20 [CI 1.30–3.75]). _Conclusions:_ Risk factors are differently related to the dominant localizations of calcifications, a finding that supports the hypothesis that the intimal and medial calcification represents a distinct etiology

Patch: platelet transfusion in cerebral haemorrhage: study protocol for a multicentre, randomised, controlled trial

<p>Abstract</p> <p>Background</p> <p>Patients suffering from intracerebral haemorrhage have a poor prognosis, especially if they are using antiplatelet therapy. Currently, no effective acute treatment option for intracerebral haemorrhage exists. Limiting the early growth of intracerebral haemorrhage volume which continues the first hours after admission seems a promising strategy. Because intracerebral haemorrhage patients who are on antiplatelet therapy have been shown to be particularly at risk of early haematoma growth, platelet transfusion may have a beneficial effect.</p> <p>Methods/Design</p> <p>The primary objective is to investigate whether platelet transfusion improves outcome in intracerebral haemorrhage patients who are on antiplatelet treatment. The PATCH study is a prospective, randomised, multi-centre study with open treatment and blind endpoint evaluation. Patients will be randomised to receive platelet transfusion within six hours or standard care. The primary endpoint is functional health after three months. The main secondary endpoints are safety of platelet transfusion and the occurrence of haematoma growth. To detect an absolute poor outcome reduction of 20%, a total of 190 patients will be included.</p> <p>Discussion</p> <p>To our knowledge this is the first randomised controlled trial of platelet transfusion for an acute haemorrhagic disease.</p> <p>Trial registration</p> <p>The Netherlands National Trial Register (NTR1303)</p

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Prevalence, associated factors and predictors of anxiety: a community survey in Selangor, Malaysia

Background: Anxiety is the most common mental health disorders in the general population. This study aimed to determine the prevalence of anxiety, its associated factors and the predictors of anxiety among adults in the community of Selangor, Malaysia. Methods: A cross sectional study was carried out in three districts in Selangor, Malaysia. The inclusion criteria of this study were Malaysian citizens, adults aged 18 years and above, and living in the selected living quarters based on the list provided by the Department of Statistics Malaysia (DOS). Participants completed a set of questionnaires, including the validated Malay version of Generalized Anxiety Disorder 7 (GAD 7) to detect anxiety. Results: Of the 2512 participants who were approached, 1556 of them participated in the study (61.90 %). Based on the cut-off point of 8 and above in the GAD-7, the prevalence of anxiety was 8.2 %. Based on the initial multiple logistic regression analysis, the predictors of anxiety were depression, serious problems at work, domestic violence and high perceived stress. When reanalyzed again after removing depression, low self-esteem and high perceived stress, six predictors that were identified are cancer, serious problems at work, domestic violence, unhappy relationship with family, non-organizational religious activity and intrinsic religiosity. Conclusion: This study reports the prevalence of anxiety among adults in the community of Selangor, Malaysia and also the magnitude of the associations between various factors and anxiety

Community food program use in Inuvik, Northwest Territories

Background: Community food programs (CFPs) provide an important safety-net for highly food insecure community members in the larger settlements of the Canadian Arctic. This study identifies who is using CFPs and why, drawing upon a case study from Inuvik, Northwest Territories. This work is compared with a similar study from Iqaluit, Nunavut, allowing the development of an Arctic-wide understanding of CFP use – a neglected topic in the northern food security literature. Methods: Photovoice workshops (n=7), a modified USDA food security survey and open ended interviews with CFP users (n=54) in Inuvik. Results: Users of CFPs in Inuvik are more likely to be housing insecure, female, middle aged (35–64), unemployed, Aboriginal, and lack a high school education. Participants are primarily chronic users, and depend on CFPs for regular food access. Conclusions: This work indicates the presence of chronically food insecure groups who have not benefited from the economic development and job opportunities offered in larger regional centers of the Canadian Arctic, and for whom traditional kinship-based food sharing networks have been unable to fully meet their dietary needs. While CFPs do not address the underlying causes of food insecurity, they provide an important service for communities undergoing rapid change, and need greater focus in food policy herein

Community vulnerability to the health effects of climate change among indigenous populations in the Peruvian Amazon : a case study from Panaillo and Nuevo Progreso

This paper presents the results of an exploratory study working with two Amazonian communities in Peru to identify key climate-related health risks from the perspective of local residents, and characterize how these risks are experienced and managed. The work adopts a vulnerability-based approach and utilizes participatory methodologies to document and examine local perspectives on vulnerability and adaptive capacity. Thirty nine community members were engaged in participatory photography (photovoice), and rapid rural appraisal workshops were conducted with a total 40 participants. Contextual information was obtained from 34 semi-structured interviews with key informants and participant observation during fieldwork. Three climate-related health risks were identified by the communities as pressing issues (food insecurity, water insecurity, and vector-borne disease), all of which are climate-dependent and reported to be being affected by observed changes in climatic conditions. Sensitivity to these risks is high due to social and economic disadvantages which force people to live in suboptimal conditions, partake in dangerous activities, and engage in unhealthy behaviors. Traditional approaches to health and strong social networks are important in moderating health risks, but are placed under increasing stress in the context of local social and economic changes due to larger scale influences, including resource development, deforestation, and changing social relations

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