Current issues in patient adherence and persistence: focus on anticoagulants for the treatment and prevention of thromboembolism

Warfarin therapy reduces morbidity and mortality related to thromboembolism. Yet adherence to long-term warfarin therapy remains challenging due to the risks of anticoagulant-associated complications and the burden of monitoring. The aim of this paper is to review determinants of adherence and persistence on long-term anticoagulant therapy for atrial fibrillation and venous thromboembolism. We evaluate what the current literature reveals about the impact of warfarin on quality of life, examine warfarin trial data for patterns of adherence, and summarize known risk factors for warfarin discontinuation. Studies suggest only modest adverse effects of warfarin on quality of life, but highlight the variability of individual lifestyle experiences of patients on warfarin. Interestingly, clinical trials comparing anticoagulant adherence to alternatives (such as aspirin) show that discontinuation rates on warfarin are not consistently higher than in control arms. Observational studies link a number of risk factors to warfarin non-adherence including younger age, male sex, lower stroke risk, poor cognitive function, poverty, and higher educational attainment. In addition to differentiating the relative impact of warfarin-associated complications (such as bleeding) versus the lifestyle burdens of warfarin monitoring on adherence, future investigation should focus on optimizing patient education and enhancing models of physician–patient shared-decision making around anticoagulation

Language Models for Image Captioning: The Quirks and What Works

Two recent approaches have achieved state-of-the-art results in image captioning. The first uses a pipelined process where a set of candidate words is generated by a convolutional neural network (CNN) trained on images, and then a maximum entropy (ME) language model is used to arrange these words into a coherent sentence. The second uses the penultimate activation layer of the CNN as input to a recurrent neural network (RNN) that then generates the caption sequence. In this paper, we compare the merits of these different language modeling approaches for the first time by using the same state-of-the-art CNN as input. We examine issues in the different approaches, including linguistic irregularities, caption repetition, and data set overlap. By combining key aspects of the ME and RNN methods, we achieve a new record performance over previously published results on the benchmark COCO dataset. However, the gains we see in BLEU do not translate to human judgments.Comment: See http://research.microsoft.com/en-us/projects/image_captioning for project informatio

An NGO-Implemented Community-Clinic Health Worker Approach to Providing Long-Term Care for Hypertension in a Remote Region of Southern India.

Poor blood pressure control results in tremendous morbidity and mortality in India where the leading cause of death among adults is from coronary heart disease. Despite having little formal education, community health workers (CHWs) are integral to successful public health interventions in India and other low- and middle-income countries that have a shortage of trained health professionals. Training CHWs to screen for and manage chronic hypertension, with support from trained clinicians, offers an excellent opportunity for effecting systemwide change in hypertension-related burden of disease. In this article, we describe the development of a program that trained CHWs between 2014 and 2015 in the tribal region of the Sittilingi Valley in southern India, to identify hypertensive patients in the community, refer them for diagnosis and initial management in a physician-staffed clinic, and provide them with sustained lifestyle interventions and medications over multiple visits. We found that after 2 years, the CHWs had screened 7,176 people over age 18 for hypertension, 1,184 (16.5%) of whom were screened as hypertensive. Of the 1,184 patients screened as hypertensive, 898 (75.8%) had achieved blood pressure control, defined as a systolic blood pressure less than 140 and a diastolic blood pressure less than 90 sustained over 3 consecutive visits. While all of the 24 trained CHWs reported confidence in checking blood pressure with a manual blood pressure cuff, 4 of the 24 CHWs reported occasional difficulty documenting blood pressure values because they were unable to write numbers properly. They compensated by asking other CHWs or members of their community to help with documentation. Our experience and findings suggest that a CHW blood pressure screening system linked to a central clinic can be a promising avenue for improving hypertension control rates in low- and middle-income countries

Mass casualty events: what to do as the dust settles?

Care during mass casualty events (MCE) has improved during the last 15 years. Military and civilian collaboration has led to partnerships which augment the response to MCE. Much has been written about strategies to deliver care during an MCE, but there is little about how to transition back to normal operations after an event. A panel discussion entitled The Day(s) After: Lessons Learned from Trauma Team Management in the Aftermath of an Unexpected Mass Casualty Event at the 76th Annual American Association for the Surgery of Trauma meeting on September 13, 2017 brought together a cadre of military and civilian surgeons with experience in MCEs. The events described were the First Battle of Mogadishu (1993), the Second Battle of Fallujah (2004), the Bagram Detention Center Rocket Attack (2014), the Boston Marathon Bombing (2013), the Asiana Flight 214 Plane Crash (2013), the Baltimore Riots (2015), and the Orlando Pulse Night Club Shooting (2016). This article focuses on the lessons learned from military and civilian surgeons in the days after MCEs

Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19.

BACKGROUND: Identifying COVID-19 patients at the highest risk of poor outcomes is critical in emergency department (ED) presentation. Sepsis risk stratification scores can be calculated quickly for COVID-19 patients but have not been evaluated in a large cohort. OBJECTIVE: To determine whether well-known risk scores can predict poor outcomes among hospitalized COVID-19 patients. DESIGNS, SETTINGS, AND PARTICIPANTS: A retrospective cohort study of adults presenting with COVID-19 to 156 Hospital Corporation of America (HCA) Healthcare EDs, March 2, 2020, to February 11, 2021. INTERVENTION: Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System-2 (NEWS2), and quick COVID-19 Severity Index (qCSI) at presentation. MAIN OUTCOME AND MEASURES: The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. Patients scored positive with qSOFA ≥ 2, Shock Index > 0.7, NEWS2 ≥ 5, and qCSI ≥ 4. Test characteristics and area under the receiver operating characteristics curves (AUROCs) were calculated. RESULTS: We identified 90,376 patients with community-acquired COVID-19 (mean age 64.3 years, 46.8% female). 17.2% of patients died in-hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA-positive, 45.1% Shock Index-positive, 49.8% NEWS2-positive, and 37.6% qCSI-positive at ED-triage. NEWS2 exhibited the highest AUROC for in-hospital mortality (0.593, confidence interval [CI]: 0.588-0.597), ICU admission (0.602, CI: 0.599-0.606), mechanical ventilation (0.614, CI: 0.610-0.619), and vasopressor receipt (0.600, CI: 0.595-0.604). CONCLUSIONS: Sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID-19 patients and are not reliable for clinical use. Severity scores should be developed using features that accurately predict poor outcomes among COVID-19 patients to develop more effective risk-based triage

Inflammatory Biomarkers Associated with Brain MRI Measures: Framingham Heart Study Offspring Cohort

Brain MRI volumes measuring brain atrophy have been associated with risks for Alzheimer’s Disease (AD) and related dementia. Inflammatory biomarkers associated with brain MRI volumes may provide insight into the neuroinflammation associated with these diseases. The study aim is to identify circulating inflammatory biomarkers associated with total and regional brain MRI volumes in the Framingham Heart Study Offspring cohort. Participants (N=662, 52% female, mean age 62 years) free of dementia and stroke at the time of blood draw and who had MRI measures within five years were profiled using the OLINK Proteomics inflammation panel. Pairwise cross-sectional associations between 68 biomarkers and eight brain MRI volumes were investigated using linear mixed-effect models accommodating familial correlations and adjusting for covariates (age, age2, sex, time between blood draw and MRI measurement, age-sex interaction, and number of APOE ε2 and ε4 alleles), using FDR≤0.1 to declare significance. APOE genotype-stratified analyses were performed to explore effect modification. Higher levels of 8 proteins were significantly associated with smaller total brain volumes (TCBV), including CDCP1, HGF, IL6, IL8, MMP10, OPG, VEGFA, and 4E-BP1. Higher levels of SCF and TWEAK were significantly associated with larger TCBV, and higher levels of SCF were also associated with larger parietal gray matter volume. In APOE ε4 carriers, higher levels of IFNγ were associated with greater white matter hyperintensity volumes. Consistent with our findings, SCF has been shown to have neuroprotective effects in animal models. Further studies are needed to confirm these potential risk and protective factors and to elucidate mechanisms

Soil indigenous microbiome and plant genotypes cooperatively modify soybean rhizosphere microbiome assembly

Background: Plants have evolved intimate interactions with soil microbes for a range of beneficial functions including nutrient acquisition, pathogen resistance and stress tolerance. Further understanding of this system is a promising way to advance sustainable agriculture by exploiting the versatile benefits offered by the plant microbiome. The rhizosphere is the interface between plant and soil, and functions as the first step of plant defense and root microbiome recruitment. It features a specialized microbial community, intensive microbe-plant and microbe-microbe interactions, and complex signal communication. To decipher the rhizosphere microbiome assembly of soybean (Glycine max), we comprehensively characterized the soybean rhizosphere microbial community using 16S rRNA gene sequencing and evaluated the structuring influence from both host genotype and soil source. Results: Comparison of the soybean rhizosphere to bulk soil revealed significantly different microbiome composition, microbe-microbe interactions and metabolic capacity. Soil type and soybean genotype cooperatively modulated microbiome assembly with soil type predominantly shaping rhizosphere microbiome assembly while host genotype slightly tuned this recruitment process. The undomesticated progenitor species, Glycine soja, had higher rhizosphere diversity in both soil types tested in comparison to the domesticated soybean genotypes. Rhizobium, Novosphingobium, Phenylobacterium, Streptomyces, Nocardioides, etc. were robustly enriched in soybean rhizosphere irrespective of the soil tested. Co-occurrence network analysis revealed dominant soil type effects and genotype specific preferences for key microbe-microbe interactions. Functional prediction results demonstrated converged metabolic capacity in the soybean rhizosphere between soil types and among genotypes, with pathways related to xenobiotic degradation, plant-microbe interactions and nutrient transport being greatly enriched in the rhizosphere. Conclusion: This comprehensive comparison of the soybean microbiome between soil types and genotypes expands our understanding of rhizosphere microbe assembly in general and provides foundational information for soybean as a legume crop for this assembly process. The cooperative modulating role of the soil type and host genotype emphasizes the importance of integrated consideration of soil condition and plant genetic variability for future development and application of synthetic microbiomes. Additionally, the detection of the tuning role by soybean genotype in rhizosphere microbiome assembly provides a promising way for future breeding programs to integrate host traits participating in beneficial microbiota assembly