Thromboembolic and neurologic sequelae of discontinuation of an antihyperlipidemic drug during ongoing warfarin therapy

Warfarin and antihyperlipidemics are commonly co-prescribed. Some antihyperlipidemics may inhibit warfarin deactivation via the hepatic cytochrome P450 system. Therefore, antihyperlipidemic discontinuation has been hypothesized to result in underanticoagulation, as warfarin metabolism is no longer inhibited. We quantified the risk of venous thromboembolism (VTE) and ischemic stroke (IS) due to statin and fibrate discontinuation in warfarin users, in which warfarin was initially dose-titrated during ongoing antihyperlipidemic therapy. Using 1999-2011 United States Medicaid claims among 69 million beneficiaries, we conducted a set of bidirectional self-controlled case series studies-one for each antihyperlipidemic. Outcomes were hospital admissions for VTE/IS. The risk segment was a maximum of 90 days immediately following antihyperlipidemic discontinuation, the exposure of interest. Time-varying confounders were included in conditional Poisson models. We identified 629 study eligible-persons with at least one outcome. Adjusted incidence rate ratios (IRRs) for all antihyperlipidemics studied were consistent with the null, and ranged from 0.21 (0.02, 2.82) for rosuvastatin to 2.16 (0.06, 75.0) for gemfibrozil. Despite using an underlying dataset of millions of persons, we had little precision in estimating IRRs for VTE/IS among warfarin-treated persons discontinuing individual antihyperlipidemics. Further research should investigate whether discontinuation of gemfibrozil in warfarin users results in serious underanticoagulation

Altitude Performance and Operational Characteristics of YJ71-A-7 Turbojet Engine

Altitude performance of a YJ71-A-7 turbojet engine, with afterburner inoperative, was determined in the NACA Lewis altitude wind tunnel over a wide range of flight conditions. Engine speed and exhaust-nozzle area were controlled independently during this investigation. The variation of corrected values of air flow, net thrust, and fuel flow with corrected engine speed was not defined by a single curve with changes in altitude at given flight Mach number. Changes in altitude had very little effect on minimum specific fuel consumption at altitudes up to 45,000 feet. There is one exhaust-nozzle schedule that is nearly optimum for all flight conditions. Performance calculated from pumping characteristics agreed with experimental values and can therefore be used to extend engine performance data

Natural Supplements for H1N1 Influenza: Retrospective Observational Infodemiology Study of Information and Search Activity on the Internet

Background: As the incidence of H1N1 increases, the lay public may turn to the Internet for information about natural supplements for prevention and treatment. Objective: Our objective was to identify and characterize websites that provide information about herbal and natural supplements with information about H1N1 and to examine trends in the public’s behavior in searching for information about supplement use in preventing or treating H1N1. Methods: This was a retrospective observational infodemiology study of indexed websites and Internet search activity over the period January 1, 2009, through November 15, 2009. The setting is the Internet as indexed by Google with aggregated Internet user data. The main outcome measures were the frequency of “hits” or webpages containing terms relating to natural supplements co-occurring with H1N1/swine flu, terms relating to natural supplements co-occurring with H1N1/swine flu proportional to all terms relating to natural supplements, webpage rank, webpage entropy, and temporal trend in search activity. Results: A large number of websites support information about supplements and H1N1. The supplement with the highest proportion of H1N1/swine flu information was a homeopathic remedy known as Oscillococcinum that has no known side effects; supplements with the next highest proportions have known side effects and interactions. Webpages with both supplement and H1N1/swine flu information were less likely to be medically curated or authoritative. Search activity for supplements was temporally related to H1N1/swine flu-related news reports and events. Conclusions: The prevalence of nonauthoritative webpages with information about supplements in the context of H1N1/swine flu and the increasing number of searches for these pages suggest that the public is interested in alternatives to traditional prevention and treatment of H1N1. The quality of this information is often questionable and clinicians should be cognizant that patients may be at risk of adverse events associated with the use of supplements for H1N1

Retrieving Nuclear Information from Protons Propagating through A Thick Target

The multiple scattering of high-energy particles in a thick target is fromulated in an impact parameter representation. A formalism similar but not identical to that of Moliere is obtained. We show that calculations of particle beam broadening due to multiple Coulomb scattering alone can be given in closed form. The focus of this study is on whether or not the broadening of the Coulomb angular distribution prevents the retrieval of nuclear-interaction information from mesauring the angular distributions of charged partiles scattered from a thick target. For this purpose, we study multiple scatterings with both the nuclear and Coulomb interactions included and we do not make a small-angle expansion. Condition for retrieving nuclear infomration from high-energy protons propagating through a block of material are obtained.Comment: 29 pages, 13 figure

The Importance of Healthy Lifestyle Behaviors in the Prevention of Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death globally. Advancements in the treatment of CVD have reduced mortality rates, yet the global burden of CVD remains high. Considering that CVD is still largely a preventable disease, prioritizing preventative measures through healthy lifestyle (HL) behaviors is necessary to lessen the burden of CVD. HL behaviors, such as regular exercise, healthy eating habits, adequate sleep, and smoking cessation, can influence a number of traditional CVD risk factors as well as a less commonly measured risk factor, cardiorespiratory fitness (CRF). It is important to note that cardiac rehabilitation programs, which traditionally have focused on secondary prevention, also emphasize the importance of making comprehensive HL behavior changes. This review discusses preventative measures to reduce the burden of CVD through an increased uptake and assessment of HL behaviors. An overview of the importance of CRF as a risk factor is discussed along with how to improve CRF and other risk factors through HL behavior interventions. The role of the clinician for promoting HL behaviors to prevent CVD is also reviewed

An Iron-Based Ecosystem Model of the Central Equatorial Pacific

The central and eastern equatorial Pacific region is characterized by lower than expected phytoplankton biomass and primary production given the relatively high ambient nitrate concentrations. These unusual conditions have spawned several field programs and laboratory experiments to determine why this high nitrate-low chlorophyll pattern persists in this region. To synthesize the results from these field programs, as well as providing additional evidence in support of the iron hypothesis, we developed a one-dimensional, nine-component ecosystem model of 0 degrees N 140 degrees W. The model components include two phytoplankton size fractions, two zooplankton size fractions, two detrital size fractions, dissolved iron, nitrate, and ammonium. The model was run for 5 years (1990-1994) and was forced using an atmospheric radiative transfer model, an ocean general circulation model (GCM), and in situ data. To our knowledge, this is the first ecosystem model at 0 degrees N 140 degrees W to synthesize the Joint Global Ocean Flux Study Equatorial Pacific Process Study (JGOFS EqPac) data set, as well as to use both in situ and modeled physical data to drive the model. Modeled phytoplankton, zooplankton, and iron all varied on interannual timescales due to El Nino events. Total phytoplankton biomass increased by as much as 40% from early 1992 (El Nino warm) to 1993 (normal). The results also indicate that the biomass increase during a cool period is not constant for each phytoplankton component, but instead the increase is most evident in the netphytoplankton (\u3e10 mu m). Netphytoplankton increase from a low of 0.1% of the total chlorophyll in 1992 to a high of 30% of the total in 1993. Microzooplankton grazing rates fluctuated in response to changes in nanophytoplankton growth rates, whereas mesozooplankton grazing was unrelated to netphytoplankton growth rates. The magnitude and temporal variability of phytoplankton chlorophyll agreed well with in situ data collected during 1992. Modeled primary production was lower than measured during El Nino but agreed with observations during normal conditions. The low primary productivity was probably a result of downwelling produced by the physical model. New production was calculated from total and recycled iron rather than nitrate-based production and was more variable in general and almost 3 times the nitrate-based new production during non-El Nino conditions

Identifying Potential Adverse Effects Using the Web: A New Approach to Medical Hypothesis Generation

Medical message boards are online resources where users with a particular condition exchange information, some of which they might not otherwise share with medical providers. Many of these boards contain a large number of posts and contain patient opinions and experiences that would be potentially useful to clinicians and researchers. We present an approach that is able to collect a corpus of medical message board posts, de-identify the corpus, and extract information on potential adverse drug effects discussed by users. Using a corpus of posts to breast cancer message boards, we identified drug event pairs using co-occurrence statistics. We then compared the identified drug event pairs with adverse effects listed on the package labels of tamoxifen, anastrozole, exemestane, and letrozole. Of the pairs identified by our system, 75–80% were documented on the drug labels. Some of the undocumented pairs may represent previously unidentified adverse drug effects

White Habits, Anti‐Racism, and Philosophy as a Way of Life

This paper examines Pierre Hadot’s philosophy as a way of life in the context of race. I argue that a “way of life” approach to philosophy renders intelligible how anti-racist confrontation of racist ideas and institutionalized white complicity is a properly philosophical way of life requiring regulated reflection on habits – particularly, habits of whiteness. I first rehearse some of Hadot’s analysis of the “way of life” orientation in philosophy, in which philosophical wisdom is understood as cultivated by actions which result in the creation of wise habits. I analyze a phenomenological claim about the nature of habit implied by the “way of life” approach, namely, that habits can be both the cause and the effect of action. This point is central to the “way of life” philosophy, I claim, in that it makes possible the intelligent redirection of habits, in which wise habits are more the effect than simply the cause of action. Lastly, I illustrate the “way of life” approach in the context of anti-racism by turning to Linda Martín Alcoff’s whiteness anti-eliminativism, which outlines a morally defensible transformation of the habits of whiteness. I argue that anti-racism provides an intelligible context for modern day forms of what Hadot calls “spiritual exercises” insofar as the “way of life” philosophy is embodied in the practice of whites seeing themselves seeing as white and seeing themselves being seen as white

Severe hypoglycemia in users of sulfonylurea antidiabetic agents and antihyperlipidemics

Drug-drug interactions causing severe hypoglycemia due to antidiabetic drugs is a major clinical and public health problem. We assessed whether sulfonylurea use with a statin or fibrate was associated with severe hypoglycemia. We conducted cohort studies of users of glyburide, glipizide, and glimepiride plus a statin or fibrate within a Medicaid population. The outcome was a validated, diagnosis-based algorithm for severe hypoglycemia. Among 592,872 persons newly exposed to a sulfonylurea+antihyperlipidemic, the incidence of severe hypoglycemia was 5.8/100 person-years. Adjusted hazard ratios (HRs) for sulfonylurea+statins were consistent with no association. Most overall HRs for sulfonylurea+fibrate were elevated, with sulfonylurea-specific adjusted HRs as large as 1.50 (95% confidence interval (CI): 1.24-1.81) for glyburide+gemfibrozil, 1.37 (95% CI: 1.11-1.69) for glipizide+gemfibrozil, and 1.63 (95% CI: 1.29-2.06) for glimepiride+fenofibrate. Concomitant therapy with a sulfonylurea and fibrate is associated with an often delayed increased rate of severe hypoglycemia