Best strategies for patient education about anticoagulation with warfarin: a systematic review

<p>Abstract</p> <p>Background</p> <p>Patient education is an essential component in quality management of the anticoagulated patient. Because it is time consuming for clinicians and overwhelming for patients, education of the anticoagulated patient is often neglected. We surveyed the medical literature in order to identify the best patient education strategies.</p> <p>Methods</p> <p>Study Selection: Two reviewers independently searched the MEDLINE and Google Scholar databases (last search March 2007) using the terms "warfarin" or "anticoagulation", and "patient education". The initial search identified 206 citations, A total of 166 citations were excluded because patients were of pediatric age (4), the article was not related to patient education (48), did not contain original data or inadequate program description (141), was focused solely on patient self-testing (1), was a duplicate citation (3), the article was judged otherwise irrelevant (44), or no abstract was available (25).</p> <p>Data Extraction: Clinical setting, study design, group size, content source, time and personnel involved, educational strategy and domains, measures of knowledge retention.</p> <p>Results</p> <p>Data Synthesis: A total of 32 articles were ultimately used for data extraction. Thirteen articles adequately described features of the educational strategy. Five programs used a nurse or pharmacist, 4 used a physician, and 2 studies used other personnel/vehicles (lay educators (1), videotapes (1)). The duration of the educational intervention ranged from 1 to 10 sessions. Patient group size most often averaged 3 to 5 patients but ranged from as low as 1 patient to as much as 11 patients. Although 12 articles offered information about education content, the wording and lack of detail in the description made it too difficult to accurately assign categories of education topics and to compare articles with one another. For the 17 articles that reported measures of patient knowledge, 5 of the 17 sites where the surveys were administered were located in anticoagulation clinics/centers. The number of questions ranged from as few as 4 to as many as 28, and questions were most often of multiple choice format. Three were self-administered, and 2 were completed over the telephone. Two reports described instruments along with formal testing of the validity and reliability of the instrument.</p> <p>Conclusion</p> <p>Published reports of patient education related to warfarin anticoagulation vary greatly in strategy, content, and patient testing. Prioritizing the educational domains, standardizing the educational content, and delivering the content more efficiently will be necessary to improve the quality of anticoagulation with warfarin.</p

Pyrophosphate-Dependent ATP Formation from Acetyl Coenzyme A in Syntrophus aciditrophicus, a New Twist on ATP Formation.

UnlabelledSyntrophus aciditrophicus is a model syntrophic bacterium that degrades key intermediates in anaerobic decomposition, such as benzoate, cyclohexane-1-carboxylate, and certain fatty acids, to acetate when grown with hydrogen-/formate-consuming microorganisms. ATP formation coupled to acetate production is the main source for energy conservation by S.&nbsp;aciditrophicus However, the absence of homologs for phosphate acetyltransferase and acetate kinase in the genome of S.&nbsp;aciditrophicus leaves it unclear as to how ATP is formed, as most fermentative bacteria rely on these two enzymes to synthesize ATP from acetyl coenzyme A (CoA) and phosphate. Here, we combine transcriptomic, proteomic, metabolite, and enzymatic approaches to show that S.&nbsp;aciditrophicus uses AMP-forming, acetyl-CoA synthetase (Acs1) for ATP synthesis from acetyl-CoA. acs1 mRNA and Acs1 were abundant in transcriptomes and proteomes, respectively, of S.&nbsp;aciditrophicus grown in pure culture and coculture. Cell extracts of S.&nbsp;aciditrophicus had low or undetectable acetate kinase and phosphate acetyltransferase activities but had high acetyl-CoA synthetase activity under all growth conditions tested. Both Acs1 purified from S.&nbsp;aciditrophicus and recombinantly produced Acs1 catalyzed ATP and acetate formation from acetyl-CoA, AMP, and pyrophosphate. High pyrophosphate levels and a high AMP-to-ATP ratio (5.9 ± 1.4) in S.&nbsp;aciditrophicus cells support the operation of Acs1 in the acetate-forming direction. Thus, S.&nbsp;aciditrophicus has a unique approach to conserve energy involving pyrophosphate, AMP, acetyl-CoA, and an AMP-forming, acetyl-CoA synthetase.ImportanceBacteria use two enzymes, phosphate acetyltransferase and acetate kinase, to make ATP from acetyl-CoA, while acetate-forming archaea use a single enzyme, an ADP-forming, acetyl-CoA synthetase, to synthesize ATP and acetate from acetyl-CoA. Syntrophus aciditrophicus apparently relies on a different approach to conserve energy during acetyl-CoA metabolism, as its genome does not have homologs to the genes for phosphate acetyltransferase and acetate kinase. Here, we show that S.&nbsp;aciditrophicus uses an alternative approach, an AMP-forming, acetyl-CoA synthetase, to make ATP from acetyl-CoA. AMP-forming, acetyl-CoA synthetases were previously thought to function only in the activation of acetate to acetyl-CoA

Search for Gravitational Waves from Scorpius X-1 in LIGO O3 Data With Corrected Orbital Ephemeris

Improved observational constraints on the orbital parameters of the low-mass X-ray binary Scorpius~X-1 were recently published in Killestein et al (2023). In the process, errors were corrected in previous orbital ephemerides, which have been used in searches for continuous gravitational waves from Sco~X-1 using data from the Advanced LIGO detectors. We present the results of a re-analysis of LIGO detector data from the third observing run of Advanced LIGO and Advanced Virgo using a model-based cross-correlation search. The corrected region of parameter space, which was not covered by previous searches, was about 1/3 as large as the region searched in the original O3 analysis, reducing the required computing time. We have confirmed that no detectable signal is present over a range of gravitational-wave frequencies from $25\textrm{Hz}$ to $1600\textrm{Hz}$, analogous to the null result of Abbott et al (2022). Our search sensitivity is comparable to that of Abbott et al (2022), who set upper limits corresponding, between $100\textrm{Hz}$ and $200\textrm{Hz}$, to an amplitude $h_0$ of about $10^{-25}$ when marginalized isotropically over the unknown inclination angle of the neutron star's rotation axis, or less than $4\times 10^{-26}$ assuming the optimal orientation.Comment: 8 pages, 3 figures, 2 tables. Typeset with AASTeX 6.3.1. Accepted for publication in The Astrophysical Journal. arXiv admin note: text overlap with arXiv:2209.0286

Patient characteristics and clinical management of patients with shoulder pain in U.S. primary care settings: Secondary data analysis of the National Ambulatory Medical Care Survey

BACKGROUND: Although shoulder pain is a commonly encountered problem in primary care, there are few studies examining its presenting characteristics and clinical management in this setting. METHODS: We performed secondary data analysis of 692 office visits for shoulder pain collected through the National Ambulatory Medical Care Survey (Survey years 1993–2000). Information on demographic characteristics, history and place of injury, and clinical management (physician order of imaging, physiotherapy, and steroid intraarticular injection) were examined. RESULTS: Shoulder pain was associated with an injury in one third (33.2% (230/692)) of office visits in this population of US primary care physicians. Males, and younger adults (age ≤ 52) more often associated their shoulder pain with previous injury, but there were no racial differences in injury status. Injury-related shoulder pain was related to work in over one-fifth (21.3% (43/202)) of visits. An x-ray was performed in 29.0% (164/566) of office visits, a finding that did not differ by gender, race, or by age status. Other imaging (CT scan, MRI, or ultrasound) was infrequently performed (6.5%, 37/566). Physiotherapy was ordered in 23.9% (135/566) of visits for shoulder pain. Younger adults and patients with a history of injury more often had physiotherapy ordered, but there was no significant difference in the ordering of physiotherapy by gender or race. Examination of the use of intraarticular injection was not possible with this data set. CONCLUSION: These data from the largest sample of patients with shoulder pain presenting to primary care settings offer insights into the presenting characteristics and clinical management of shoulder pain at the primary care level. The National Ambulatory Medical Care Survey is a useful resource for examining the clinical management of specific symptoms in U.S. primary care offices

Interpreting the Si II and C II line spectra from the COS Legacy Spectroscopic SurveY using a virtual galaxy from a high-resolution radiation-hydrodynamic simulation

Observations of low-ionization state (LIS) metal lines provide crucial insights into the interstellar medium of galaxies, yet, disentangling the physical processes responsible for the emerging line profiles is difficult. This work investigates how mock spectra generated using a single galaxy in a radiation-hydrodynamical simulation can help us interpret observations of a real galaxy. We create 22,500 C II and Si II spectra from the virtual galaxy at different times and through multiple lines of sight and compare them with the 45 observations of low-redshift star-forming galaxies from the COS Legacy Spectroscopic SurveY (CLASSY). We find that the mock profiles provide accurate replicates to the observations of 38 galaxies with a broad range of stellar masses ($10^6$ to $10^9$ $M_\odot$) and metallicities (0.02 to 0.55 $Z_\odot$). Additionally, we highlight that aperture losses explain the weakness of the fluorescent emission in several CLASSY spectra and must be accounted for when comparing simulations to observations. Overall, we show that the evolution of a single simulated galaxy can produce a large diversity of spectra whose properties are representative of galaxies of comparable or smaller masses. Building upon these results, we explore the origin of the continuum, residual flux, and fluorescent emission in the simulation. We find that these different spectral features all emerge from distinct regions in the galaxy's ISM, and their characteristics can vary as a function of the viewing angle. While these outcomes challenge simplified interpretations of down-the-barrel spectra, our results indicate that high-resolution simulations provide an optimal framework to interpret these observations.Comment: Accepted for publication in Ap

CLASSY VII Ly\alpha\ Profiles: The Structure and Kinematics of Neutral Gas and Implications for LyC Escape in Reionization-Era Analogs

Lyman-alpha line profiles are a powerful probe of ISM structure, outflow speed, and Lyman continuum escape fraction. In this paper, we present the Ly$\alpha$ line profiles of the COS Legacy Archive Spectroscopic SurveY, a sample rich in spectroscopic analogs of reionization-era galaxies. A large fraction of the spectra show a complex profile, consisting of a double-peaked Ly$\alpha$ emission profile in the bottom of a damped, Ly$\alpha$ absorption trough. Such profiles reveal an inhomogeneous interstellar medium (ISM). We successfully fit the damped Ly$\alpha$ absorption (DLA) and the Ly$\alpha$ emission profiles separately, but with complementary covering factors, a surprising result because this approach requires no Ly$\alpha$ exchange between high-$N_\mathrm{HI}$ and low-$N_\mathrm{HI}$ paths. The combined distribution of column densities is qualitatively similar to the bimodal distributions observed in numerical simulations. We find an inverse relation between Ly$\alpha$ peak separation and the [O III]/[O II] flux ratio, confirming that the covering fraction of Lyman-continuum-thin sightlines increases as the Ly$\alpha$ peak separation decreases. We combine measurements of Ly$\alpha$ peak separation and Ly$\alpha$ red peak asymmetry in a diagnostic diagram which identifies six Lyman continuum leakers in the CLASSY sample. We find a strong correlation between the Ly$\alpha$ trough velocity and the outflow velocity measured from interstellar absorption lines. We argue that greater vignetting of the blueshifted Ly$\alpha$ peak, relative to the redshifted peak, is the source of the well-known discrepancy between shell-model parameters and directly measured outflow properties. The CLASSY sample illustrates how scattering of Ly$\alpha$ photons outside the spectroscopic aperture reshapes Ly$\alpha$ profiles as the distances to these compact starbursts span a large range.Comment: 40 pages, 19 figures, 5 tables, submitted to ApJ, comments welcom

Teaching appropriate interactions with pharmaceutical company representatives: The impact of an innovative workshop on student attitudes

BACKGROUND: Pharmaceutical company representatives (PCRs) influence the prescribing habits and professional behaviour of physicians. However, the skills for interacting with PCRs are not taught in the traditional medical school curriculum. We examined whether an innovative, mandatory workshop for third year medical students had immediate effects on knowledge and attitudes regarding interactions with PCRs. METHODS: Surveys issued before and after the workshop intervention solicited opinions (five point Likert scales) from third year students (n = 75) about the degree of bias in PCR information, the influence of PCRs on prescribing habits, the acceptability of specific gifts, and the educational value of PCR information for both practicing physicians and students. Two faculty members and one PCR led the workshop, which highlighted typical physician-PCR interactions, the use of samples and gifts, the validity and legal boundaries of PCR information, and associated ethical issues. Role plays with the PCR demonstrated appropriate and inappropriate strategies for interacting with PCRs. RESULTS: The majority of third year students (56%, 42/75) had experienced more than three personal conversations with a PCR about a drug product since starting medical school. Five percent (4/75) claimed no previous personal experience with PCRs. Most students (57.3%, 43/75) were not aware of available guidelines regarding PCR interactions. Twenty-eight percent of students (21/75) thought that none of the named activities/gifts (lunch access, free stethoscope, textbooks, educational CD-ROMS, sporting events) should be restricted, while 24.0% (8/75) thought that students should be restricted only from sporting events. The perceived educational value of PCR information to both practicing physicians and students increased after the workshop intervention from 17.7% to 43.2% (chi square, p = .0001), and 22.1% to 40.5% (p = .0007), respectively. Student perceptions of the degree of bias of PCR information decreased from 84.1% to 72.9% (p = .065), but the perceived degree of influence on prescribing increased (44.2% to 62.1% (p = .02)). CONCLUSIONS: Students have exposure to PCRs early in their medical training. A single workshop intervention may influence student attitudes toward interactions with PCRs. Students were more likely to acknowledge the educational value of PCR interactions and their impact on prescribing after the workshop intervention

CLASSY VIII: Exploring the Source of Ionization with UV ISM diagnostics in local High-zz Analogs

In the current JWST era, rest-frame UV spectra play a crucial role in enhancing our understanding of the interstellar medium (ISM) and stellar properties of the first galaxies in the epoch of reionization (EoR, $z>6$). Here, we compare well-known and reliable optical diagrams sensitive to the main ionization source (i.e., star formation, SF; active galactic nuclei, AGN; shocks) to UV counterparts proposed in the literature - the so-called ``UV-BPT diagrams'' - using the HST COS Legacy Archive Spectroscopic SurveY (CLASSY), the largest high-quality, high-resolution and broad-wavelength range atlas of far-UV spectra for 45 local star-forming galaxies. In particular, we explore where CLASSY UV line ratios are located in the different UV diagnostic plots, taking into account state-of-the-art photoionization and shock models and, for the first time, the measured ISM and stellar properties (e.g., gas-phase metallicity, ionization parameter, carbon abundance, stellar age). We find that the combination of C III] $\lambda\lambda$1907,9 He II $\lambda1640$ and O III] $\lambda$1666 can be a powerful tool to separate between SF, shocks and AGN at sub-solar metallicities. We also confirm that alternative diagrams without O III] $\lambda$1666 still allow us to define a SF-locus with some caveats. Diagrams including C IV $\lambda\lambda$1548,51 should be taken with caution given the complexity of this doublet profile. Finally, we present a discussion detailing the ISM conditions required to detect UV emission lines, visible only in low gas-phase metallicity (12+log(O/H) $\lesssim8.3$) and high ionization parameter (log($U$) $\gtrsim-2.5$) environments. Overall, CLASSY and our UV toolkit will be crucial in interpreting the spectra of the earliest galaxies that JWST is currently revealing.Comment: 31 pages, submitted to ApJ, comments welcom

First narrow-band search for continuous gravitational waves from known pulsars in advanced detector data

Spinning neutron stars asymmetric with respect to their rotation axis are potential sources of continuous gravitational waves for ground-based interferometric detectors. In the case of known pulsars a fully coherent search, based on matched filtering, which uses the position and rotational parameters obtained from electromagnetic observations, can be carried out. Matched filtering maximizes the signalto- noise (SNR) ratio, but a large sensitivity loss is expected in case of even a very small mismatch between the assumed and the true signal parameters. For this reason, narrow-band analysis methods have been developed, allowing a fully coherent search for gravitational waves from known pulsars over a fraction of a hertz and several spin-down values. In this paper we describe a narrow-band search of 11 pulsars using data from Advanced LIGO’s first observing run. Although we have found several initial outliers, further studies show no significant evidence for the presence of a gravitational wave signal. Finally, we have placed upper limits on the signal strain amplitude lower than the spin-down limit for 5 of the 11 targets over the bands searched; in the case of J1813-1749 the spin-down limit has been beaten for the first time. For an additional 3 targets, the median upper limit across the search bands is below the spin-down limit. This is the most sensitive narrow-band search for continuous gravitational waves carried out so far

The COS Legacy Archive Spectroscopy SurveY (CLASSY) Treasury Atlas

Far-ultraviolet (FUV; ~1200-2000 angstroms) spectra are fundamental to our understanding of star-forming galaxies, providing a unique window on massive stellar populations, chemical evolution, feedback processes, and reionization. The launch of JWST will soon usher in a new era, pushing the UV spectroscopic frontier to higher redshifts than ever before, however, its success hinges on a comprehensive understanding of the massive star populations and gas conditions that power the observed UV spectral features. This requires a level of detail that is only possible with a combination of ample wavelength coverage, signal-to-noise, spectral-resolution, and sample diversity that has not yet been achieved by any FUV spectral database. We present the COS Legacy Spectroscopic SurveY (CLASSY) treasury and its first high level science product, the CLASSY atlas. CLASSY builds on the HST archive to construct the first high-quality (S/N_1500 >~ 5/resel), high-resolution (R~15,000) FUV spectral database of 45 nearby (0.002 < z < 0.182) star-forming galaxies. The CLASSY atlas, available to the public via the CLASSY website, is the result of optimally extracting and coadding 170 archival+new spectra from 312 orbits of HST observations. The CLASSY sample covers a broad range of properties including stellar mass (6.2 < logM_star(M_sol) < 10.1), star formation rate (-2.0 < log SFR (M_sol/yr) < +1.6), direct gas-phase metallicity (7.0 < 12+log(O/H) < 8.8), ionization (0.5 < O_32 < 38.0), reddening (0.02 < E(B-V < 0.67), and nebular density (10 < n_e (cm^-3) < 1120). CLASSY is biased to UV-bright star-forming galaxies, resulting in a sample that is consistent with z~0 mass-metallicity relationship, but is offset to higher SFRs by roughly 2 dex, similar to z >~2 galaxies. This unique set of properties makes the CLASSY atlas the benchmark training set for star-forming galaxies across cosmic time.Comment: Accepted for publication in Ap