Thromboprophylaxis in atrial fibrillation and association with cognitive decline: systematic review

Objective:Atrial Fibrillation (AF) is associated with dementia. If AF-related cognitive decline is driven by cerebral embolic events, thromboprophylaxis may impact on this. This systematic review assessed the association between cognitive impairment and AF thromboprophylaxis. Methods:Two independent reviewers searched CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science Core Collection, and Cochrane Library from inception until 12th November 2014. Eligible studies compared AF thromboprophylaxis to control with an outcome measure of cognition or dementia. Where data allowed, meta-analyses describing between-group differences in cognitive test scores or rates of incident dementia were performed. Results:Nineteen studies were eligible. For two prospective studies (one RCT) comparing anticoagulation against antiplatelet therapy, change in Mini-Mental State Examination score from baseline to last follow-up (maximal duration:5.9 years) suggested a difference favouring anticoagulation (mean difference:0.90, 95% CI:0.29 to 1.51), in keeping with a trend seen in the single RCT (mean difference MMSE:0.80. 95% CI:-0.07 to 1.67). Pooled odds ratios suggested no association with incident dementia, comparing anticoagulant to antiplatelet therapy (two studies, OR:1.23, 95% CI:0.80 to 1.91) or no treatment (three studies, OR:0.89, 95%CI:0.47 to 1.69). Conclusions:Our analyses show no definitive evidence of cognitive benefit or harm from anticoagulation. We demonstrated a potential benefit of anticoagulation in comparison to antiplatelet over time. Larger-scale studies with longer follow-up are needed to determine the true cognitive impact of AF thromboprophylaxis

OTIVM, MATERIALIDADE E PAISAGEM NAS VILLAE DO ALTO ALENTEJO PORTUGUÊS EM ÉPOCA ROMANA

A arquitectura das villae foi cuidadosamente pensada para permitir o máximo des- frute de uma vivência de gosto urbano e cosmopolita. A atenção dada à inserção da construção na paisagem, as soluções para harmonizar o espaço exterior criando atmosferas favoráveis, a contemplação para o exterior e a criação de espaços e am- bientes construídos que permitissem potenciar o otium e o convivium são discutidos neste trabalho, com exemplos de sítios no Alto Alentejo

Chronic kidney disease, time in therapeutic range and adverse clinical outcomes in anticoagulated patients with non-valvular atrial fibrillation: observations from the SPORTIF trials

Background: Chronic kidney disease (CKD) is highly prevalent in atrial fibrillation (AF) patients and associated with an increased risk of adverse outcomes. Our objectives were to study clinical features associated with CKD in AF patients and the impact of CKD on anticoagulation control, as reflected by time in therapeutic range (TTR). We also determined the impact of CKD and TTR in predicting adverse outcomes. Methods and Results: We analysed pooled datasets from SPORTIF III and V trials, including 3646 patients assigned to warfarin with data on renal function. CKD (creatinine clearance . 70%, whilst diabetes mellitus, aspirin use and CKD were inversely associated with TTR. >. 70%. On Cox regression analysis, CKD was an independent predictor for stroke (p = 0.006) and death (p . 70% was independently associated with a lower risk of stroke (p = 0.024), death (p = 0.001) and major bleeding (p = 0.001). Conclusions: CKD is highly prevalent amongst AF patients and a risk factor for stroke and death. Adjusting for CKD, good quality anticoagulation control (TTR. >. 70%) was an independent predictor for lower risks of stroke, death and major bleeding

Cognitive behavioural therapy for depression, anxiety and stress in caregivers of dementia patients:a systematic review and meta-analysis

Background and Objectives There is limited evidence for the efficacy of cognitive behavioral therapy (CBT) in managing psychological morbidities in caregivers of dementia patients. To evaluate changes in dementia caregivers’ depression, anxiety, and stress following CBT. Also to assess quality of life, intervention adherence/satisfaction and therapy effectiveness using different formats, frequencies, and delivery methods. Research Design and Methods Studies were identified through electronic bibliographic searches (MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library) and from gray literature (Conference Proceedings Citation Index and clinicaltrials.gov). Data were pooled for meta-analysis. Results Twenty-five studies were included. Depression (standardized mean difference [SMD] = −0.34; 95% confidence interval [CI] −0.47 to −0.21; p < .001) and stress (SMD = −0.36; 95% CI: −0.52 to −0.20; p < .001) were significantly reduced after CBT, relative to comparator groups, while anxiety was not (SMD = 0.10; 95% CI: −0.18 to 0.39; p = .47). A subgroup analysis demonstrated that statistically significant reductions in depression and stress were limited to group, but not individual, formats. An additional subgroup analysis revealed that eight CBT sessions or fewer were equally effective as more than eight sessions at significantly reducing depression and stress, relative to comparator groups. Furthermore, analysis with independent samples t-tests demonstrated no statistically significant differences between mean changes in depression (MD = 0.79; 95% CI: −0.45 to 2.03; p = .21) and stress (MD = 0.21; 95% CI: −1.43 to 1.85; p = .80) when directly comparing CBT groups of ≤8 and >8 sessions. Discussion and Implications Group CBT provides small but significant benefits to caregivers’ depression and stress. Therapy cost-effectiveness may be improved by limiting therapy to group formats and eight sessions

Patients’ and health professionals’ views and experiences of atrial fibrillation and oral-anticoagulant therapy:a qualitative meta-synthesis

Objective - Atrial fibrillation (AF) patients are prescribed oral-anticoagulant (OAC) therapy, often warfarin, to reduce stroke risk. We explored existing qualitative evidence about patients’ and health professionals’ experiences of OAC therapy. Methods - Systematic searches of eight bibliographic databases were conducted. Quality was appraised using the Critical Appraisal Skills Programme tool and data from ten studies were synthesised qualitatively. Results - Four third-order constructs, emerged from the final step in the analysis process: (1) diagnosing AF and the communication of information, (2) deciding on OAC therapy, (3) challenges revolving around patient issues, and (4) healthcare challenges. Synthesis uncovered perspectives that could not be achieved through individual studies. Conclusion - Physicians’ and patients’ experiences present a dichotomy of opinion on decision-making, which requires further exploration and changes in practice. Outcomes of workload pressure on both health professionals and patients should be investigated. The need for on-going support and education to patients and physicians is critical to achieve best practice and treatment adherence. Practice implications - Such research could encourage health professionals to understand and attend better to the needs and concerns of the patient. Additionally these findings can be used to inform researchers and healthcare providers in developing educational interventions with both patients and health professionals

Use of NOACs in the Perioperative Management of Patients with Atrial Fibrillation::To Stop, Bridge or Continue?

Over the last decade, the availability of non-vitamin K antago- nist oral anticoagulants (NOACs) has significantly changed the daily clinical practice in managing thromboembolic risk in patients with atrial fibrillation (AF).1 Guidelines for AF man- agement have established that NOACs are the preferred treat- ment for the majority of AF patients;2 however, recent data from ‘real-life’ registries clearly show that a significant pro- portion of patients are still treated with vitamin K antago- nists.3–8 Nevertheless, the role of NOACs still seems to be debated in some specific circumstances, such as their role in the peri-operative management of patients with AF, in relation to interruption or continuation of anticoagulation