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The impact of ischaemic stroke on atrial fibrillation-related healthcare cost: a systematic review. - Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology
The aim of this study was to summarize healthcare costs incurred by patients with atrial fibrillation (AF) who developed ischaemic stroke, explore factors associated with increased cost, and highlight the importance of anticoagulation therapy for stroke prophylaxis. A systematic literature search of PubMed, EMBASE, Web of Science, and the health economic evaluation database was conducted up to December 2015. Studies focused on the cost and/or resource utilization of ischaemic stroke in patients with AF were included. Reported costs were converted to international dollars (I$) and adjusted to 2015 values. Alongside the narrative review of included studies, Spearman's correlation, independent-samples t-test, and one-way ANOVA were used to explore factors associated with cost differences between studies. Sixteen studies published from nine countries were identified. Based on currency conversion rates in 2015, ischaemic stroke-related healthcare costs were estimated to be I$41 420, I$12 895, and I$8184 for high-income, upper middle-income, and lower middle-income economies, respectively. Local GDP per capita accounted for âˆ¼50% of the healthcare cost variation among countries. Major component of overall cost was from hospitalization. Ischaemic stroke incurring in patients with AF â‰¥75 years was 2.3 times that of their younger peers (P = 0.049). The economic burden from ischaemic stroke in patients with AF is considerable with positive association to country income. Clinicians and stakeholders should be aware of the importance of anticoagulation therapies in stroke prophylaxis, the occurrence of stroke, and the downstream economic burden on an increasingly ageing population.Published on behalf of the European Society of Cardiology. All rights reserved. Â© The Author 2016. For permissions please email: firstname.lastname@example.org.
Graphene Topographies: Multiscale Graphene Topographies Programmed by Sequential Mechanical Deformation (Adv. Mater. 18/2016). - Advanced materials (Deerfield Beach, Fla.)
P.-Y. Chen, R. H. Hurt, I. Y. Wong and co-workers demonstrate a hierarchical graphene surface architecture generated by using various sequences and combinations of extreme mechanical deformation, as shown in the false-colored SEM image. As described on page 3564, the sequential patterning approach enables the design of feature sizes and orientations across multiple length scales which are retained during mechanical deformations of similar extent. This results in sequence-dependent surface topographies with structural memory.Â© 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.
Association Between Acute Neuropsychiatric Events and Helicobacter pylori Therapy Containing Clarithromycin. - JAMA internal medicine
There is a concern that Helicobacter pylori therapy containing clarithromycin might be associated with acute neuropsychiatric events.To examine the association between H pylori therapy containing clarithromycin and acute neuropsychiatric events.A self-controlled case series study was conducted using the Clinical Data Analysis and Reporting System database in Hong Kong to explore any association. The exposure of interest was H pylori therapy containing clarithromycin in the outpatient setting. Study patients, 18 years or older at cohort entry, must have had both exposure to H pylori therapy containing clarithromycin and their first recorded neuropsychiatric events between January 1, 2003, and December 31, 2012. A post hoc nested case-control analysis was also performed in patients receiving H pylori therapy containing clarithromycin.The primary outcome was composite neuropsychiatric events, while secondary outcomes were psychotic events and cognitive impairment. Risk periods in the self-controlled case series analysis were defined as 14-day preexposure period, current use (days 1-14 since prescription start date) and recent use (days 15-30). Age-adjusted incidence rate ratios (IRR) were estimated using the conditional Poisson regression.Of 66 559 patients who had at least 1 outpatient prescription of H pylori therapy containing clarithromycin. Their mean (SD) age at cohort entry was 50.8 (14.8 years); their mean age at first exposure was 55.4 (14.8) years, and 30 910 were male (46.4%). A total of 1824 patients had their first recorded composite neuropsychiatric events during the study period. An increased IRR of 4.12 (35 composite neuropsychiatric events during 72 person-years; 95% CI, 2.94-5.76) during current use was observed but not in recent use (9 events during 82 person-years; IRR, 0.95; 95% CI, 0.49-1.83) and 14-day preexposure period (14 events during 72 person-years; IRR, 1.63; 95% CI, 0.96-2.77) vs baseline (1766 events during 16 665 person-years). Similarly, both the risk of psychotic events and cognitive impairment increased during current use vs baseline, although this subsequently returned to baseline incidence levels during recent use. The crude absolute risks of composite neuropsychiatric events, psychotic events, and cognitive impairment during current use were 0.45, 0.12, and 0.12 per 1000 prescriptions, respectively. The nested case-control analysis also gave similar results to that of the self-controlled case series analysis.This study shows evidence of a short-term increased risk of neuropsychiatric events associated with H pylori therapy containing clarithromycin.
Net Clinical Benefit of Dabigatran Over Warfarin in Patients With Atrial Fibrillation Stratified by CHA2DS2-VASc and Time in Therapeutic Range. - The Canadian journal of cardiology
Although dabigatran is 1 of the preferred agents for stroke prevention in atrial fibrillation, warfarin remains the mainstay treatment in many publicly financed health care systems. Little is known about the net clinical benefit of switching patients who are receiving warfarin and have different risk profiles and time in therapeutic range (TTR) to dabigatran. In this study, we aimed to investigate the net clinical benefit of switching warfarin to dabigatran in relation to CHA2DS2-VASc and TTR.This was a hospital-based observational registry.A total of 2153 patients (72.7 Â± 12.2 years; CHA2DS2-VASc, 3.65 Â± 1.94) were included in the analysis: 1686 patients were receiving warfarin, and 467 were receiving dabigatran. After a 4.2-year follow-up, the incidence of ischemic stroke among patients receiving warfarin and dabigatran were 4.25%/y and 1.89%/y, respectively. Among patients receiving warfarin, ischemic stroke risk was positively correlated with CHA2DS2-VASc score and negatively correlated with TTR. It was found on regression analysis that for every 10% increase in TTR, the incidence of annual ischemic stroke decreased by 0.74%/y (R(2)Â = 0.77; PÂ = 0.04). Patients with higher CHA2DS2-VASc scores had greater ischemic stroke risk reductions per 10% TTR increment (ie, for CHA2DS2-VASc score â‰¤ 2, 3-4, and â‰¥ 5, the reductions wereÂ -0.38%/y,Â -0.60%/y, andÂ -0.84%/y, respectively). Similar trends were also observed in intracranial hemorrhage. The net clinical benefit favoured switching from warfarin to dabigatran for all patients, but the best benefit was found in those with high CHA2DS2-VASc and poor TTR.The combination of CHA2DS2-VASc and TTR facilitates patient prioritization for dabigatran. The best net clinical benefit for switching from warfarin to dabigatran was found in those with both high CHA2DS2-VASc and poor TTR.Copyright Â© 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Evaluation of the risk of cardiovascular events with clarithromycin using both propensity score and self-controlled study designs. - British journal of clinical pharmacology
Some previous studies suggest a long term association between clarithromycin use and cardiovascular events. This study investigates this association for clarithromycin given as part of Helicobacter pylori treatment (HPT).Our source population was the Clinical Practice Research Datalink (CPRD), a UK primary care database. We conducted a self-controlled case series (SCCS), a case-time-control study (CTC) and a propensity score adjusted cohort study comparing the rate of cardiovascular events in the 3â€‰years after exposure to HPT containing clarithromycin with exposure to clarithromycin free HPT. Outcomes were first incident myocardial infarction, arrhythmia and stroke. For the cohort analysis we included secondary outcomes all-cause and cardiovascular mortality.28,552 patients were included in the cohort. The incidence rate ratio of first MI within a year of exposure to HPT containing clarithromycin was 1.07 (95% CI: 0.85-1.34, pâ€‰=â€‰0.58) and within 90â€‰days was 1.43 (95% CI: 0.99-2.09 pâ€‰=â€‰0.057) in the SCCS analysis. CTC and cohort results were consistent with these findings.There was some evidence for a short term association for first MI but none for a long term association for any outcome.This article is protected by copyright. All rights reserved.
A simple modification to the 25-gauge trocar and cannula system for retinopathy of prematurity related lens-sparing vitrectomy. - BMC ophthalmology
Recently, 25-gauge vitrectomy has become more popular. However, most still perform the surgery in pediatric patients without the use of the trocars and cannulas as in adult vitrectomies.We described a simple modification using adult 25-gauge cannulas and 270-silicone watzke sleeves, enabling these instruments to be used in pediatric cases. The sleeve is cut into segments of 2Â mm in length, and then introduced up the shaft of the 25-gauge trocar. One is introduced first, and a second one is introduced on top of the first one. This secures the two sleeves on the shaft of the trocar, such that they act as a spacer. The effective shaft of the trocar was then reduced to 2Â mm in length.This method enabled successful surgery in two cases.This allows the adaptation of the standard 25-gauge system for pediatric cases with only the slightest modification needed.
Association between oral fluoroquinolones and seizures: A self-controlled case series study. - Neurology
The aim of this study was to investigate the association and to estimate the crude absolute risk of seizure among patients exposed to fluoroquinolones (FQs) in Hong Kong and the United Kingdom.A self-controlled case series study was conducted. Data were collected from the Hong Kong Clinical Data Analysis and Reporting System database and the Clinical Practice Research Datalink. Patients who were prescribed any oral FQ and had an incident seizure diagnosis from 2001 to 2013 were included. The risk windows were defined as pre-FQ start, FQ-exposed, and post-FQ completion. Incidence rate ratios were estimated in all risk windows and compared with baseline periods. A post hoc subgroup analysis was conducted to examine the effect of patients with a history of seizure.An increased incidence rate ratio was found in the pre-FQ start periods and no association was found in the post-FQ completion periods in both databases. The crude absolute risk of an incident seizure in 10,000 oral FQ prescriptions was 0.72 (95% confidence interval 0.47-1.10) in the Clinical Data Analysis and Reporting System and 0.40 (95% confidence interval 0.30-0.54) in the Clinical Practice Research Datalink. The rate ratio during treatment was not higher than pre-FQ start periods among patients with a history of seizure, therefore the results did not raise serious concerns.This study does not support a causal association between the use of oral FQs and the subsequent occurrence of seizure. An increased risk before the FQ exposure period suggests that the clinical indication for which FQ was prescribed may have contributed to the development of seizure rather than the drug itself.Â© 2016 American Academy of Neurology.
Effect of suboptimal anticoagulation treatment with antiplatelet therapy and warfarin on clinical outcomes in patients with nonvalvular atrial fibrillation: A population-wide cohort study. - Heart rhythm : the official journal of the Heart Rhythm Society
The actual consequence of suboptimal anticoagulation management in patients with nonvalvular atrial fibrillation (NVAF) is unclear in the real-life practice.The purpose of this study was to identify the prevalence of suboptimally anticoagulated patients with NVAF and compare the effectiveness and safety of antiplatelet drugs with warfarin.We performed a retrospective cohort study using a population-wide database managed by the Hong Kong Hospital Authority. Patients newly diagnosed with NVAF during 2010-2013 were included in the analysis. A Cox proportional hazards regression model with 1:1 propensity score matching was used to compare the risk of ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between patients receiving antiplatelet drugs and those receiving warfarin stratified by level of international normalized ratio (INR) control.Of the 35,551 patients with NVAF, 30,294 (85.2%) had a CHA2DS2-VASc (congestive heart failure, hypertension, age â‰¥75 years [doubled], diabetes mellitus, age 65-74 years, prior stroke/transient ischemic attack [doubled], vascular disease, and sex category [female]) score of â‰¥2 (target group for anticoagulation). Of these, 7029 (23.2%) received oral anticoagulants and 18,508 (61.1%) received antiplatelet drugs alone. There were 1541 (67.7%) of warfarin users who had poor INR control (time in therapeutic range [2.0-3.0] <60%). Patients receiving warfarin had comparable risks of intracranial hemorrhage (hazard ratio [HR] 1.24; 95% confidence interval [CI] 0.65-2.34) and gastrointestinal bleeding (HR 1.23; 95% CI 0.84-1.81) and lower risk of ischemic stroke (HR 0.40; 95% CI 0.28-0.57) and all-cause mortality (HR 0.45; 95% CI 0.36-0.57) than did patients receiving antiplatelet drugs alone. Good INR control was associated with a reduced risk of ischemic stroke (HR 0.48; 95% CI 0.27-0.86) as compared with poor INR control. Modeling analyses suggested that ~40,000 stroke cases could be potentially prevented per year in the Chinese population if patients were optimally treated.More than three-quarters of high-risk patients among this Chinese population with NVAF were not anticoagulated or had poor INR control. There is an urgent need to improve the optimization of anticoagulation for stroke prevention in patients with atrial fibrillation.Copyright Â© 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Use of the SAMe-TT2R2 Score to Predict Good Anticoagulation Control with Warfarin in Chinese Patients with Atrial Fibrillation: Relationship to Ischemic Stroke Incidence. - PloS one
The efficacy and safety of warfarin therapy for stroke prevention in atrial fibrillation (AF) depends on the time in therapeutic range (TTR). We aimed to assess the predictive ability of SAMe-TT2R2 score in Chinese AF patients on warfarin, whose TTR is notoriously poor.This is a single-centre retrospective study. Patients with non-valvular AF on warfarin diagnosed between 1997 and 2011 were stratified according to SAMe-TT2R2 score, and TTR was calculated using Rosendaal method. The predictive power of SAMe-TT2R2 scores for good TTR i.e. >70% was assessed. We included 1,428 Chinese patients (mean age 76.2Â±8.7 years, 47.5% male) with non-valvular AF on warfarin. The mean and median TTR were 38.2Â±24.4% and 38.8% (interquartile range: 17.9% and 56.2%) respectively. TTR decreased progressively with increasing SAMe-TT2R2 score (p = 0.016). When the cut-off value of SAMe-TT2R2 score was set to 2, the sensitivity and specificity to predict TTR<70% were 85.7% and 17.8%, respectively. The corresponding positive and negative predictive values were 10.1% and 92.0%. After a mean follow-up of 4.7Â±3.6 years, 338 patients developed an ischemic stroke (4.96%/year). Patients with TTRâ‰¥70% had a lower annual risk of ischemic stroke of 3.67%/year compared with than those with TTR<70% (5.13%/year)(p = 0.08). Patients with SAMe-TT2R2 score â‰¤2 had the lowest risk of annual risk of ischemic stroke (3.49%/year) compared with those with SAMe-TT2R2 score = 3 (4.56%/year), and those with SAMe-TT2R2 score â‰¥4 (6.41%/year)(p<0.001). There was also a non-significant trend towards more intracranial hemorrhage with increasing SAMe-TT2R2 score.The SAMe-TT2R2 score correlates well with TTR in Chinese AF patients, with a score >2 having high sensitivity and negative predictive values for poor TTR. Ischemic stroke risk increased progressively with increasing SAMe-TT2R2 score, consistent with poorer TTRs at high SAMe-TT2R2 scores.
Reports of Perceived Adverse Events of Stimulant Medication on Cognition, Motivation, and Mood: Qualitative Investigation and the Generation of Items for the Medication and Cognition Rating Scale. - Journal of child and adolescent psychopharmacology
There is no questionnaire to specifically monitor perceived adverse events of methylphenidate (MPH) on cognition, motivation, and mood. The current study therefore had two goals. First, to harvest accounts of such putative events from transcripts of interviews in samples enriched for such potential experiences. Second, to use the derived data to generate items for a new questionnaire that can be used for monitoring such events in medication trials or routine clinical care.Following a literature search aimed at identifying associations between MPH and cognition and/or motivation, a qualitative semistructured interview was designed to focus specifically on the domains of cognition (i.e., reasoning, depth/breadth of thinking, intellectual capacity, and creativity) and motivation (i.e., drive, effort, and attitudes toward rewards/incentives). Interviews were conducted with 45 participants drawn from the following four groups: (a) clinicians, child and adolescent psychiatrists, and pediatricians specializing in attention-deficit/hyperactivity disorder (ADHD) (nâ€‰=â€‰15); (2) teachers, with experience of teaching at least 10 medicated children with ADHD (nâ€‰=â€‰10); (3) parents of children with ADHD (nâ€‰=â€‰8) treated with MPH; and (4) adolescents/adults with ADHD (nâ€‰=â€‰12). Purposeful sampling was used to selectively recruit ADHD participants whose histories suggested a degree of vulnerability to MPH adverse events. Data were analyzed using a deductive approach to content analysis.While we probed purposefully for cognitive and motivational adverse events, a third domain, related to mood, emerged from the reports. Therefore, three domains, each with a number of subdomains, were identified from the interview accounts: (i) Cognition (six subdomains; attention/concentration, changes in thinking, reduced creativity, sensory overload, memory, slower processing speed); (ii) motivation (four subdomains; loss of intrinsic motivation for goal-directed activities, external locus of control, lack of effort/engagement in daily tasks, increased focus on incentives); and (iii) mood (three subdomains; dampening of spontaneity/flat affect, mood dysregulation, increased anxiety/edginess). On the basis of these reports, 34 items were specified and incorporated into a prototype questionnaire, which was piloted and refined on the basis of field-testing.Items were identified that capture potential/perceived cognitive, motivational, and mood-related adverse events of MPH. The items generated will allow us to further develop and psychometrically examine their prevalence, and the extent to which they are associated with medication adherence, treatment outcome, impairment, and other reported adverse events (e.g., loss of appetite/cardiovascular effects).
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