Implications of bleeding in acute coronary syndrome and percutaneous coronary intervention

The advent of potent antiplatelet and antithrombotic agents over the past decade has resulted in significant improvement in reducing ischemic events in acute coronary syndrome (ACS). However, the use of antiplatelet and antithrombotic combination therapy, often in the settings of percutaneous coronary intervention (PCI), has led to an increase in the risk of bleeding. In patients with non-ST elevation myocardial infarction treated with antithrombotic agents, bleeding has been reported to occur in 0.4%–10% of patients, whereas in patients undergoing PCI, periprocedural bleeding occurs in 2.2%–14% of cases. Until recently, bleeding was considered an intrinsic risk of antithrombotic therapy, and efforts to reduce bleeding have received little attention. There have been increasing data demonstrating that bleeding is associated with adverse outcomes, including myocardial infarction, stroke, and death. Therefore, it is imperative to optimize patient outcomes by adopting pharmacological and nonpharmacological strategies to minimize bleeding while maximizing treatment efficacy. In this paper, we present a review of the bleeding classifications used in large-scale clinical trials in patients with ACS and those undergoing PCI treated with antiplatelets and antithrombotic agents, adverse outcomes, particularly mortality associated with bleeding complications, and suggested predictive risk factors. Potential mechanisms of the association between bleeding and mortality and strategies to reduce bleeding complications are also discussed

2017 update on pain management in patients with chronic kidney disease

The prevalence of pain has been reported to be \u3e60–70% among patients with advanced and end-stage kidney disease. Although the underlying etiologies of pain may vary, pain per se has been linked to lower quality of life and depression. The latter is of great concern given its known association with reduced survival among patients with end-stage kidney disease.We herein discuss and update the management of pain in patients with chronic kidney disease with and without requirement for renal replacement therapy with the focus on optimizing pain control while minimizing therapy-induced complications

Antithrombotic strategies in patients undergoing percutaneous coronary intervention for acute coronary syndrome

In patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), both periprocedural acute myocardial infarction and bleeding complications have been shown to be associated with early and late mortality. Current standard antithrombotic therapy after coronary stent implantation consists of lifelong aspirin and clopidogrel for a variable period depending in part on the stent type. Despite its well-established efficacy in reducing cardiac-related death, myocardial infarction, and stroke, dual antiplatelet therapy with aspirin and clopidogrel is not without shortcomings. While clopidogrel may be of little beneficial effect if administered immediately prior to PCI and may even increase major bleeding risk if coronary artery bypass grafting is anticipated, early discontinuation of the drug may result in insufficient antiplatelet coverage with thrombotic complications. Optimal and rapid inhibition of platelet activity to suppress ischemic and thrombotic events while minimizing bleeding complications is an important therapeutic goal in the management of patients undergoing percutaneous coronary intervention. In this article we present an overview of the literature on clinical trials evaluating the different aspects of antithrombotic therapy in patients undergoing PCI and discuss the emerging role of these agents in the contemporary era of early invasive coronary intervention. Clinical trial acronyms and their full names are provided in Table 1

Agroforestry - The Most Resilient Farming System for the Hilly Northwest of Vietnam

Over 94% of the land of northwestern Vietnam is classified as sloping. Population growth has exerted pressure on local natural resources, with agricultural expansion on steep slopes resulting in forest degradation, landscape fragmentation and severe environmental consequences. Efforts to restore forest ecosystems have been made by the government, however, as the livelihoods of 80% of the population depend on agriculture, the reconversion of land to forest has proven to be an inappropriate solution. Agroforestry offers a potentially sustainable land-use solution, which could re-establish forests, restore ecosystem services, and stabilize local livelihoods. In this paper, we assess the potential of agroforestry development in the region based on the results of two interrelated surveys conducted in 21 representative villages in six districts of three northwestern provinces: 1) a farming system diagnosis implemented in 17 representative villages; and 2) an agroforestry adoption survey with 210 households practising agroforestry in 14 villages. The analysis was strengthened by four years’ experience in implementing an extensive agroforestry project in the region. The studies focussed on assessing key benefits and constraints of existing farming systems, including agroforestry practices, adopted by farmers and identifying the potential for agroforestry development in the region. The results showed that the dominant farming system in the north-western provinces was monoculture of staple crops on slopes, which provided relatively low economic returns. Soil erosion, land degradation, and water shortages resultant from intensive farming practices were the most significant environmental issues in the area. Tree-based farming systems were rare and mostly a result of spontaneous adoption by farmers. Given the mountainous landscape and the need for soil stabilization, agroforestry was seen by farmers as a viable approach. Improving the existing and adopting new, integrated agroforestry systems were identified as viable ways toward sustainable livelihoods in Northwestern Vietnam

New method for measuring azimuthal distributions in nucleus-nucleus collisions

The methods currently used to measure azimuthal distributions of particles in heavy ion collisions assume that all azimuthal correlations between particles result from their correlation with the reaction plane. However, other correlations exist, and it is safe to neglect them only if azimuthal anisotropies are much larger than 1/sqrt(N), with N the total number of particles emitted in the collision. This condition is not satisfied at ultrarelativistic energies. We propose a new method, based on a cumulant expansion of multiparticle azimuthal correlations, which allows to measure much smaller values of azimuthal anisotropies, down to 1/N. It is simple to implement and can be used to measure both integrated and differential flow. Furthermore, this method automatically eliminates the major systematic errors, which are due to azimuthal asymmetries in the detector acceptance.Comment: final version (misprints corrected), to be published in Phys.Rev.

Appropriate Antibiotic Use and Associated Factors in Vietnamese Outpatients

Background: Inappropriate antibiotic use among outpatients is recognized as the primary driver of antibiotic resistance. A proper understanding of appropriate antibiotic usage and associated factors helps to determine and limit inappropriateness. We aimed to identify the rate of appropriate use of antibiotics and identify factors associated with the inappropriate prescriptions. Methods: We conducted a cross-sectional descriptive study in outpatient antibiotic use at a hospital in Can Tho City, Vietnam, from August 1, 2019, to January 31, 2020. Data were extracted from all outpatient prescriptions at the Medical Examination Department and analyzed by SPSS 18 and Chi-squared tests, with 95% confidence intervals. The rationale for antibiotic use was evaluated through antibiotic selection, dose, dosing frequency, dosing time, interactions between antibiotics and other drugs, and general appropriate usage. Results: A total of 420 prescriptions were 51.7% for females, 61.7% with health insurance, and 44.0% for patients with one comorbid condition. The general appropriate antibiotic usage rate was 86.7%. Prescriptions showed that 11.0% and 9.5% had a higher dosing frequency and dose than recommended, respectively; 10.2% had an inappropriate dosing time; 3.1% had drug interactions; and only 1.7% had been prescribed inappropriate antibiotics. The risk of inappropriate antibiotic use increased in patients with comorbidities and antibiotic treatment lasting >7 days (p < 0.05). Conclusions: The study indicated a need for more consideration when prescribing antibiotics to patients with comorbidities or using more than 7 days of treatment

Is the analysis of flow at the CERN SPS reliable?

Several heavy ion experiments at SPS have measured azimuthal distributions of particles with respect to the reaction plane. These distributions are deduced from two-particle azimuthal correlations under the assumption that they result solely from correlations with the reaction plane. In this paper, we investigate other sources of azimuthal correlations: transverse momentum conservation, which produces back-to-back correlations, resonance decays, HBT correlations and final state interactions. These correlations increase with impact parameter: most of them vary with the multiplicity N like 1/N. When they are taken into account, the experimental results of the NA49 collaboration at SPS are significantly modified. These correlations might also explain an important fraction of the pion directed flow observed by WA98. Data should be reanalyzed taking into account carefully these non--flow correlations.Comment: Revised version (minor corrections), 13 pages, LaTeX, 6 Postscript figures included. Submitted to Physical Review

Flow analysis from multiparticle azimuthal correlations

We present a new method for analyzing directed and elliptic flow in heavy ion collisions. Unlike standard methods, it separates the contribution of flow to azimuthal correlations from contributions due to other effects. The separation relies on a cumulant expansion of multiparticle azimuthal correlations, and includes corrections for detector inefficiencies. This new method allows the measurement of the flow of identified particles in narrow phase-space regions, and can be used in every regime, from intermediate to ultrarelativistic energies.Comment: 31 pages, revtex. Published version (references added

Opposing Effects of Prior Infection versus Prior Vaccination on Vaccine Immunogenicity against Influenza A(H3N2) Viruses

Prior vaccination can alternately enhance or attenuate influenza vaccine immunogenicity and effectiveness. Analogously, we found that vaccine immunogenicity was enhanced by prior A(H3N2) virus infection among participants of the Ha Nam Cohort, Viet Nam, but was attenuated by prior vaccination among Australian Health Care Workers (HCWs) vaccinated in the same year. Here, we combined these studies to directly compare antibody titers against 35 A(H3N2) viruses spanning 1968–2018. Participants received licensed inactivated vaccines containing A/HongKong/4801/2014 (H3N2). The analysis was limited to participants aged 18–65 Y, and compared those exposed to A(H3N2) viruses circulating since 2009 by infection (Ha Nam) or vaccination (HCWs) to a reference group who had no recent A(H3N2) infection or vaccination (Ha Nam). Antibody responses were compared by fitting titer/titer-rise landscapes across strains, and by estimating titer ratios to the reference group of 2009–2018 viruses. Pre-vaccination, titers were lowest against 2009–2014 viruses among the reference (no recent exposure) group. Post-vaccination, titers were, on average, two-fold higher among participants with prior infection and two-fold lower among participants with 3–5 prior vaccinations compared to the reference group. Titer rise was negligible among participants with 3–5 prior vaccinations, poor among participants with 1–2 prior vaccinations, and equivalent or better among those with prior infection compared to the reference group. The enhancing effect of prior infection versus the incrementally attenuating effect of prior vaccinations suggests that these exposures may alternately promote and constrain the generation of memory that can be recalled by a new vaccine strain.Annette Fox, Louise Carolan, Vivian Leung, Hoang Vu Mai Phuong, Arseniy Khvorov, Maria Auladell, Yeu-Yang Tseng, Pham Quang Thai, Ian Barr, Kanta Subbarao, Le Thi Quynh Mai, H. Rogier van Doorn, and Sheena G. Sulliva