Use of warfarin in long-term care: a systematic review

<p>Abstract</p> <p>Background</p> <p>The use of warfarin in older patients requires special consideration because of concerns with comorbidities, interacting medications, and the risk of bleeding. Several studies have suggested that warfarin may be underused or inconsistently prescribed in long-term care (LTC); no published systematic review has evaluated warfarin use for stroke prevention in this setting. This review was conducted to summarize the body of published original research regarding the use of warfarin in the LTC population.</p> <p>Methods</p> <p>A systematic literature search of the PubMed, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was conducted from January 1985 to August 2010 to identify studies that reported warfarin use in LTC. Studies were grouped by (1) rates of warfarin use and prescribing patterns, (2) association of resident and institutional characteristics with warfarin prescribing, (3) prescriber attitudes and concerns about warfarin use, (4) warfarin management and monitoring, and (5) warfarin-related adverse events. Summaries of study findings and quality assessments of each study were developed.</p> <p>Results</p> <p>Twenty-two studies met the inclusion criteria for this review. Atrial fibrillation (AF) was the most common indication for warfarin use in LTC and use of warfarin for stroke survivors was common. Rates of warfarin use in AF were low in 5 studies, ranging from 17% to 57%. These usage rates were low even among residents with high stroke risk and low bleeding risk. Scored bleeding risk had no apparent association with warfarin use in AF. In physician surveys, factors associated with not prescribing warfarin included risk of falls, dementia, short life expectancy, and history of bleeding. International normalized ratio was in the target range approximately half of the time. The combined overall rate of warfarin-related adverse events and potential events was 25.5 per 100 resident months on warfarin therapy.</p> <p>Conclusions</p> <p>Among residents with AF, use of warfarin and maintenance of INR levels to prevent stroke appear to be suboptimal. Among prescribers, perceived challenges associated with warfarin therapy often outweigh its benefits. Further research is needed to explicitly consider the appropriate balancing of risks and benefits in this frail patient population.</p

Extraction of pure components from overlapped signals in gas chromatography-mass spectrometry (GC-MS)

Gas chromatography-mass spectrometry (GC-MS) is a widely used analytical technique for the identification and quantification of trace chemicals in complex mixtures. When complex samples are analyzed by GC-MS it is common to observe co-elution of two or more components, resulting in an overlap of signal peaks observed in the total ion chromatogram. In such situations manual signal analysis is often the most reliable means for the extraction of pure component signals; however, a systematic manual analysis over a number of samples is both tedious and prone to error. In the past 30 years a number of computational approaches were proposed to assist in the process of the extraction of pure signals from co-eluting GC-MS components. This includes empirical methods, comparison with library spectra, eigenvalue analysis, regression and others. However, to date no approach has been recognized as best, nor accepted as standard. This situation hampers general GC-MS capabilities, and in particular has implications for the development of robust, high-throughput GC-MS analytical protocols required in metabolic profiling and biomarker discovery. Here we first discuss the nature of GC-MS data, and then review some of the approaches proposed for the extraction of pure signals from co-eluting components. We summarize and classify different approaches to this problem, and examine why so many approaches proposed in the past have failed to live up to their full promise. Finally, we give some thoughts on the future developments in this field, and suggest that the progress in general computing capabilities attained in the past two decades has opened new horizons for tackling this important problem

Quantitative metabolomics based on gas chromatography mass spectrometry: status and perspectives

Metabolomics involves the unbiased quantitative and qualitative analysis of the complete set of metabolites present in cells, body fluids and tissues (the metabolome). By analyzing differences between metabolomes using biostatistics (multivariate data analysis; pattern recognition), metabolites relevant to a specific phenotypic characteristic can be identified. However, the reliability of the analytical data is a prerequisite for correct biological interpretation in metabolomics analysis. In this review the challenges in quantitative metabolomics analysis with regards to analytical as well as data preprocessing steps are discussed. Recommendations are given on how to optimize and validate comprehensive silylation-based methods from sample extraction and derivatization up to data preprocessing and how to perform quality control during metabolomics studies. The current state of method validation and data preprocessing methods used in published literature are discussed and a perspective on the future research necessary to obtain accurate quantitative data from comprehensive GC-MS data is provided

Endothelial dysfunction, angiotensin-converting enzyme inhibitors and calcium antagonists.

The endothelium plays a crucial role in the pathogenesis of cardiovascular disease. Endothelial function is attenuated by the presence of different well known cardiovascular risk factors. Evaluation of endothelial vasodilator function serve as an index integrating the overall stress imposed by cardiovascular risk factors and reinforce the suggestion that endothelial dysfunction is an early marker of cardiovascular disease that precedes clinical manifestations. Angiotensin-converting enzyme inhibitors have been shown to reduce the cardiovascular mortality, an effect that could be the consequence of an improvement in the endothelial function. Recent studies have shown that a calcium antagonist might improve the endothelial function, however, there is controversy about this action and also about the potential mechanisms for the effect of a calcium antagonist in the regulation of endothelial function

Haul-out behaviour of the world's northernmost population of harbour seals (Phoca vitulina) throughout the year

<div><p>The harbour seal population in Svalbard occurs at the northernmost limit of the species' range. It experiences environmental extremes far beyond the norm for this species, including an extended period of polar night and extensive sea ice cover. In 2009 and 2010, 60 harbour seals (30 pups + 30 immature/mature seals) from this population were equipped with Satellite-Relay Data Loggers (SRDLs) to study their haul-out behaviour, with a special focus on the winter period. Using a combination of Generalized Additive Mixed Models and Cox Proportional Hazard models, the influences of sex, maturity, temporal, spatial and environmental factors on haul-out behaviour were explored. All of the seals continued to haul out even through the coldest periods during the polar night, though clear seasonality in the time spent hauled out daily was displayed by both immature and mature seals. Time spent hauled out daily decreased from ∼5.2 hrs in September to ∼1.2 hrs in February in these age groups, while pups displayed less seasonality (∼2.4 hrs/day throughout most of the year). The average at-sea period also exhibited seasonality, increasing to a maximum of ∼1.6 days in February (monthly maxima for individual animals ranged from 7 <b>to</b> 19 days). The seals showed a strong preference to haul out at low tide when hauling out on land but not when using sea ice as a haul-out platform. A diel rhythm in haul-out behaviour was present during the months with day–night cycling and midnight sun but not during the polar night. Haul-out behaviour was impacted to a greater extent by air pressure, through its effect on wind speed, than by absolute temperature values. The extreme environment in Svalbard likely causes some physiological challenges that might impact survival rates negatively, particularly among pups. Climate warming is likely to have positive effects on Svalbard's harbour seal population.</p></div